Miiiiiiiiliiili^^ 


II, 


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>irii 


ATLAS 


OF 


CLINICAL  SURGERY 

WITH   SPECIAL   REFERENCE  TO 

DIAGNOSIS    AND     TREATMENT 

FOR 

PRACTITIONERS  AND  STUDENTS 

BY 

Dr.  Ph.  Bockenheimer 

Professor    of    Surgery    in    the    University    of    Berlin. 


ENGLISH    ADAPTATION 

BY 

C.  F.  Marshall,  M.D.,  F.R.C.S. 

Late  Assistant  Surgeon  to  the   Hospital  for  Diseases  of  the  Skin,   London. 


2SHitt)  150  Colored  Jfigurcs 

From  Models  by  F.   Kolbow  in  the  Pathoplastic  Institute  of  Berlin. 


>*'*K>^; 


NEW  YORK 
REBMAN  COMPANY 

1123   BROADWAY 


Copyright,  190S,  bv 

REBMAN    COMPANY 

New  York 


Entered  at  Stationers'  Hall,  liondon,  England 


All  rights  reserved 


Printed  in  A  nierica 


Biomrdical 
Library 


WO 
517 


Preface 


Those  who  are  acquainted  with  the  history  of 
medicine  know  that,  even  in  ancient  times,  it  was 
sought  to  represent  pictures  of  diseases  by  the  aid 
of  plastic  art.  No  wonder  then  that,  at  the  present 
day,  when  medicine  has  made  such  great  progress 
in  all  domains,  we  take  advantage  of  all  measures 
which  may  facilitate  the  study  of  morbid  conditions. 
The  rich  material  of  von  Bergviann's  clinic,  which 
has  been  placed  at  my  disposal,  renders  it  possible 
to  give  plastic  representations  of  all  surgical  dis- 
eases which  are  suitable  for  reproduction  in  this  way. 
The  models  were  executed  with  the  greatest  skill  by 
F.  Kolbow  in  the  pathoplastic  institute  at  Berlin, 
and  have  proved  of  much  value  in  the  teaching  of 
clinical  surgery. 

The  models  have  been  reproduced  by  the  four- 
color  process,  which  gives  a  more  natural  appear- 
ance than  can  be  obtained  in  reproduction  by  water 
colors. 

In  this  work  clinical  pictures  have  been  repre- 
sented with  a  view  to  assist  the  practitioner  in  diag- 
nosis, and  to  give  the  student  a  survey  of  the  more 
important  surgical  diseases.  For  this  purpose,  the 
malignant  and  benign  tumors,  a  number  of  pyogenic, 
tuberculous  and  syphilitic  conditions  which  are 
common  in  surgical  practice  have  been  figured  and 
described,  along  with  numerous  other  cases  which 
belong  to  the  domain  of  surgery. 

In  the  text,  which  represents  the  teaching  of  von 
Bergmann's  school,   all   cases  described   have  been 

iii 


67.S7W 


under  the  author's  observation.  Diagnosis,  differ- 
ential diagnosis,  prognosis  and  treatment  are  dealt 
with  from  the  modern  standpoint. 

The  author  begs  to  acknowledge  his  indebtedness 
to  his  master,  the  late  Professor  von  Bergmann,  and 
thinks  this  can  be  expressed  in  no  better  way  than 
by  an  endeavor  to  give  a  true  exposition  of  his 
teaching,  which  will  always  remain  a  landmark  in 
the  science  of  surgery. 

Ph.    Bockenheimer. 

Berlin. 


IV 


Translator's  Preface 

With  the  exception  of  Lister,  few  surgeons  have 
had  more  influence  on  the  progress  of  surgical  science 
than  the  late  Professor  von  Bergviann.  We  are, 
therefore,  much  indebted  to  Professor  Bockenheimer 
for  placing  before  us  the  teaching  of  von  Benjmann's 
school  in  a  concise  and  practical  form.  The  repro- 
ductions of  Kolbow's  models  have  been  executed 
with  remarkable  skill,  and  give  a  most  faithful  and 
life-like  representation  of  the  various  diseases. 

In  this  English  adaptation  I  have  followed  the 

original   text   pretty   closely.     I  have  added  a  few 

paragraphs  in  brackets  where  they  appeared  to  be 

useful. 

C.  F.  Marshall. 

27  New  Cavendish  Street,  London,  W. 


Complete 

Index  of  Plates 


Plate 

Abscess,  gununatoiis XCV 

Abscess,  subcutaneous LXVII 

Acne  rosacea — Rhinophyma LIV 

Acromegaly — llacromelia — Macroglossia CXX 

Actinomycosis,  incipient XCII 

Actinomycosis,  progressive XCIII 

Amputations,  amniotic C'XIX 

Aneurism,  arterial LXIV 

Angiosarcoma  of  skin XIX 

Anthrax — Malignant  pustule XC 

Anthrax,  necrosis XCI 

Arthritis,  gonorrheal  phlegmonous LXXXIX 

.\rthritis,  gouty CXIII 

Arthritis,  tuberculous   fibrous — osseous  anchy- 
losis    C 

Arthritis,  tuberculous  fibrous — white  tumor.  ...  CI 
Arthritis,  tuberculous  fungous — fibrous  anchy- 
losis    XCIX 

.\rthritis,  tuberculous  purulent C 

Atheromatous  cyst — carcinoma  of  skin XII 

Bronchocele XXXIII 

Biu-ns CVIII 

Bum,  X-ray CX 

Bursitis,  prepatellar XXXI 

Carbuncle .  LXX 

Carcinoma  of  breast — cancer  en  cuirasse X 

Carcinoma  of  breast — carcinomatous   lymphan- 
gitis   XI 

Carcinoma  of  breast — carcinomatous  lymphoma  V 

Carcinoma  of  breast — disseminations IX 

Carcinoma  of  brea.st — Paget's  disease VIII 

Carcinoma  of  breast,  ulcerated VI 

Carcinoma  of  face I 

Carcinoma  of  forehead I 

Carcinoma  of  leg  after  burn XIV 

Carcinoma  of  lip II 

Carcinoma  of  lip — lupus Ill 

Carcinoma  of  nipple VII 

Carcinoma  of  nose II 

Carcinoma  of  penis — leukoplakia XIII 

Carcinoma  of  skin  in  cicatri.x XV 

Carcinoma  of  skin  after  wart XV 

vii 


"igure 

Page 

121 

299 

,  314 

85 

189 

70 

140 

150 

381, 

,410 

115 

293 

116 

293 

119 

331 

,408 

82 

169 

26 

34,46 

112 

287 

113 

287 

111 

282 

141 

377 

127 

317, 

,338 

128 

317; 

,339 

125 

317, 

,335 

126 

317, 

,337 

18 

24 

44 

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355 

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365 

42 

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89 

202 

15 

16 

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16 

1 

1 

2 

1 

20 

30 

3 

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5 

6 

12 

16 

4 

1 

19 

27 

22 

30 

21 

30 

Plate  Figure 

Carcinoma  of  tongue,  incipient IV  8 

Carcinoma  of  tongue,  ulcerated — leukoplakia .  .  IV  9 

Carcinoma  and  papilloma  of  tongue IV  7 

Chancre  of  tongue,  syphilitic XCIV  118 

Chondromyxosarcoma — malignant  exostosis. . .  .  XXVI  34 

Cla\iis — purulent  arthritis LXXIX  100 

Contracture,  aponeurotic  (Dupuytren) XLVI  60 

Contracture,  ischaemic XLVIII  63 

Contracture,  tendinous  (after  whitlow) XLVII  61 

Dactylitis  tuberculotis — spina  ventosa CIV  131 

Dermoid XXXVI  48 

Dermoid — phimosis XXXV  47 

Dermoid,  recurrent XXXV  46 

Detachment  of  skin LVII  73 

Dislocation  with  fracture  of  leg — Pseudarthrosis.  LI  66 

Duct,  persistent  omphalomesenteric CXVIII  147 

Elephantiasis  nervorum — Fibromata  moUusca.  .  LIV  69 

Elephantiasis  of  penis,  Ij-mphangiectatic LV  71 

Encephalocele,  occipital — Rhachischisis CXIV  142 

Enchondroma  of  hand XXXVII  50 

Endothelioma  of  parotid — Mixed  timaour XXX  40 

Endothelioma  of  skin XXIX  39 

Erysipelas,  erj'thematous LXXI  90 

Erysipelas,  hemorrhagic  bullous LXXII  91 

Erj-sipeloid LXXIII  92 

Fibro-adenoma  of  mamma,  cystic XXVIII  37 

Fil)rolipoma,  pendulous  subcutaneous XXXIX  52 

Fibroma  of  tendon  sheath XXXVII  49 

Fistula,  median  of  neck XLIV  57 

Fistula,  from  foreign  body XLIII  56 

Frost-bite CIX  137 

Furunculosis LXIX  88 

Furimculus — Lj-mphangitis LXIX  87 

Ganghon,  carpal XXXI  41 

Gangrene,  carbolic CVII  135 

Gangrene,  diabetic — .Arteriosclerosis CXII  140 

Gangrene,  dry — Mummification CV  133 

Gangrene,  moist — Decubital  ulcer CVI  134 

Gangrene  moist,  of  foot CIV  132 

Gumma  of  the  lip  and  nose XCV  120 

Gumma  of  the  tongue XCIV  119 

Hallux    valgus  —  hammer-toe  —  Arthrogenous 

contracture XLIX  64 

Hemangioma LVIII  75 

Hemangioma,  cavernous,  of  tongue XXVII  36 

Hemangioma,  cavernous  subcutaneous LXII  80 

Hemangioma,  cutaneous  and  subcutaneous  tel- 
angiectases    LXIII  81 

Hemarthrosis  —  compression  of  ulnar  nerve — 

neurogenous  contracture XLVII  62 

Hematoma,  diffuse — Hemophilia LIX  77 

Hemorrhoids — Fibromata  ani XXXVIII  51 

Hernia,  congenital  umbilical CXVIII  148 

viii 


Page 
6 

6 
6 

299, 311 
34,62 
232 
115 
122 
118 

317. 343 
92 
92 
92 

148 

132 

381,404 

139 

142 

381,383 

99 

77 

74 

204 

208 

211 

69 

104 

96 

110 

109 

360 

196 

196 

80 

354 

370 

345 

350 

317. 344 
299.313 
299,  312 

126 

152 

66 

166 


168 

120 
156 
102 
406 


.381 


Plate 

Horn,  cutaneous — Sebaceous  adenoma XXIX 

Hygroma,  multilocular XXXII 

Infection,  generalized LXXXVI 

Keloid,  after  laparotomy XLV 

Keloid,  after  vaccination XLV 

Lipoma,  diffuse  subcutaneous XL 

Lipoma,  symmetrical  subcutaneous XLI 

Lj-mphadenitis,  circumscribed  suppurative.  .  .  .  XCII 

Lymphadenitis,  diffuse  (Bubo) LXXXVIII 

Lymphangioma,  congenital  multiple CXVII 

Lymphoma,  tuberculous,  of  neck XCVIII 

LjTnphosarcoma  of  neck XVII 

Mastitis,  purulent  puerpural LXVIII 

Melanocarcinoma  of  skin,  after  wart XVI 

Melanosarcoma  of  skin — Sarcomatous  lymphoma  XX 

Myelocele — Pes  varus CXV 

Myelocystocele — Mj^olipoma CXVI 

Ncevus,  neuromatous — X'eurofibroma  of  skin. .  .  .  LIII 

Nebvus,  pigmented  hairy LII 

Nsevus,  vascular LIX 

Nseviis,  warty — Carcinoma  of  skin XII 

CEdema.   malignant — Gangrenous   emphysema- 
tous phlegmon LXXXVII 

Osteomyelitis,  chronic,  of  humerus LXXXIV 

Osteomyelitis  of  lower  maxilla LXXXII 

Osteomyelitis,  acute LXXXIII 

Osteomyelitis  of  tibia — X'ecrosis LXXXV 

Ostitis,  giimmatous XCVI 

Othematoma LVIII 

Papilloma  of  skin,  inflanmiatory XXXIV 

Papilloma  of  tongue IV 

Paronychia LXXVIII 

Perforating  ulcer  of  foot — Raynaud's  gangrene.  CXI 

Periostitis,  purulent  alveolar — Parulis LXXXI 

Petechise  and  hemorrhage,  by  compression LXI 

Phlegmon  of  neck — Wooden  phlegmon LXXX 

Phlegmon,  progressive  putrefactive LXXIX 

Rickets — Greenstick  fracture L 

Sarcoma,     epipharj'ngeal  —  malignant     nasal 

polypus XVIII 

Sarcoma  of  fascia,  ulcerated XXV 

Sarcoma,  fungoid,  of  orbit XIX 

Sarcoma,  giant  celled — Epulis XXVII 

Sarcoma  of  humerus,  peripheral XXIV 

Sarcoma  of  mamma,  cystic XXII 

Sarcoma  of  mamma,  ulcerated XXI 

Sarcoma  of  skin,  multiple XXIII 

Skin-grafting XLII 

Suggillations  and  Suffusions — Subcutaneous  and 

Hematoma LX 

Teratoma,  monogerminal CXVII 

Thrombophlebitis,  acute  purulent LXVI 

Tongue,  geographical  (Marginate  glossitis) XCIV 

ix 


Figure 

Page 

38 

72 

43 

84 

108 

261 

59 

113 

58 

113 

53 

104 

54 

104 

114 

292 

110 

278 

145 

381,397 

124 

317,334 

24 

34 

86 

192 

23 

32  ,39 

28 

34,48 

143 

381,388 

144 

381,388 

68 

136 

67 

134 

76 

155 

17 

24 

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274 

106 

244, 259 

104 

244, 255 

105 

244, 257 

107 

244, 260 

122 

299,315 

74 

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45 

90 

6 

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367 

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241 

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102 

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101 

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34,42 

33 

34,60 

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34,46 

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34,64 

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34,55 

30 

34,49 

29 

34,49 

31 

34,52 

55 

108 

78 

160 

146 

381,401 

84 

186 

117 

298 

Plate 

Tuberculosis  of  hand CIII 

Tuberculosis  of  testicle CII 

Ulcer,  gummatous XCVII 

Ulcer,  varicose — Elephantiasis — Pachydermia.  .  LVI 

Unguis  incarnatus  (Ingrowing  toe-nail) LXXVIII 

Varix,  cirsoid — Pes  valgus LXV 

Whitlow,  iiit«rdigital LXXVII 

Whitlow,  osteal  and  articular LXXVI 

Whitlow,  subcutaneous — Lymphangitis LXXV 

Whitlow,  subepidermal LXXIV 

Whitlow,  tendinous LXXVII 


Figure 

Page 

130 

317,342 

129 

317,  341 

123 

299 

72 

145 

99 

230 

83 

174 

97 

213,227 

95 

213, 224 

94 

213, 223 

93 

213, 222 

96 

213, 226 

Bockenlieiiiier,  Atlas. 


Tab.  1. 


E 

o 


U 


IE 


E 
c 


u 


Rehiiian  roni|)anv.  New-Vork 


Cutaneous  Carcinoma 

CARCINOMA  PLANUM  FACIEI  (o/  the  Face) 

Plate  I,  Fig.  1. 
CARCINOMA  FRONTIS  {of  the  Forehead) 

Plate  I,  Fig.  2. 
CARCINOMA  NASI  {of  the  Nose) 

Plate  n,  Fig.  4. 

Cutaneous  cancers  of  the  face  are  of  great  im- 
portance because  they  constitute  almost  a  tenth  part 
of  all  cases  of  cancer  {Gurlt,  Heivxann).  The  nose, 
eyelids,  cheeks,  temples  and  forehead  come  in  the 
first  line,  while  the  chin  and  ears  are  least  affected. 
In  youth,  these  tumors  very  seldom  occur,  and  then 
originate  in  various  ways  from  the  basis  of  a  Xero- 
derma pigmentosum  (Kaposi).  From  the  fortieth 
to  the  seventieth  year  the  disease  is  common  and 
develops  from  pre-existing  warts,  cutaneous  horns, 
adenomata,  dermoid  or  atheromatous  cysts  {H. 
Wolff),  as  well  as  from  diseases  which  cause  chronic 
irritation  of  the  skin  (erysipelas,  eczema,  tuberculous 
and  syphilitic  ulceration). 

In  old  country  people  the  flat  cutaneous  carcinoma 
(Figs.  1  and  2)  occurs  very  frequently,  and  can  be 
traced  to  early  wrinkling  of  the  skin,  uncleanliness 
and  senile  seborrhea,  causing  an  accumulation  of 
dirty  scales  on  the  skin.  By  scratching  this  epider- 
mic accumulation,  superficial  easily  bleeding  sores 
are  formed,  which,  however,  heal  quickly  so  long  as 
they  are  not  cancerous. 

The  Carcinoma  planum  faciei  {von  Schnh's 
"ulcus  rodens")  presents  itself  at  first  as  a  hard, 
flat,  reddish  nodule,  which,  when  scratched  or  broken, 

1 


forms  a  flat  ulcer  with  little  tendency  to  heal.  Of 
slow  growth,  and  only  attaining  a  conspicuous 
size  after  some  years,  it  generally  remains  a  long 
time  unnoticed  by  the  patient,  especially  as  it  causes 
no  inconvenience.  When  it  presents  itself  as  a 
growing  superficial  ulceration,  this  generally  has  a 
circular  form  with  hard,  raised  edges  of  overlapping 
thinned  epidermis;  while  the  floor  of  the  ulcer  is, 
for  the  most  part,  soft  at  first,  and  the  whole  growth 
is  movable  over  the  deeper  structures. 

In  the  region  of  the  chin  especially  there  is  a  re- 
semblance to  the  syphilitic  chancre  or  gumma,  but 
the  base  of  the  cancerous  ulcer  is  distinguished  by 
manifold  irregularities  and  fissures.  Easily  bleed- 
ing granulations  alternate  with  more  yellowish,  fatty 
looking  parts  (Fig.  1).  It  is  characteristic  of  these 
cutaneous  carcinomata  that  plugs  the  size  of  a  pin's 
head  can  be  pressed  from  the  yellow  surface  of  the 
ulcer;  microscopic  examination  shows  that  these 
consist  of  broken-down,  fatty,  cancer  cells.  The 
ulcer  is  often  covered  by  a  scab  so  that  the  diagnosis 
is  only  possible  after  its  removal.  As  the  tumor 
extends  there  appear  radiating  contractions  of  the 
surrounding  skin  and  consequent  deformity  (of  the 
eyelids,  for  example).  The  original  circular  shape 
is  then  often  wanting,  and  the  outline  becomes  irreg- 
ular (Fig.  2).  At  first  superficial,  the  tumor  may 
after  some  years  extend  to  the  deeper  parts  and 
cause  extensive  destruction;  for  instance,  of  the 
bones  of  the  face  (Fig.  4).  This  deep  extension  is 
especially  seen  in  parts  where  the  subcutaneous 
fatty  tissue  is  not  developed  (the  temples,  bridge  of 
the  nose  and  zygomatic  arch,  Figs.  2  and  4).  The 
deep  growth  is  evident  at  the  commencement  in  the 
slight  mobility  of  the  tumor  over  the  subjacent 
structures. 

On  account  of  the  spontaneous  cicatrization, 
which  may  take  place  at  different  parts  of  the  ulcer 
or  over  its  whole  surface,  although  it  is  not  perma- 

2 


nent,  these  growths  were  formerly  wrongly  placed  in 
the  group  of  benign  tumors  (canci'oid).  Their  mi- 
croscopic structure  is  in  most  cases  that  of  squamous- 
celled,  epithelial  cancer,  which  by  extension  into  the 
deep  glandular  regions  may  later  on  cause  metas- 
tatic growths  in  the  organs  (Virchow). 

Differential  Diagnosis.  Carcinoma  is  distin- 
guished from  papilloma  or  adenoma  by  its  hard 
edges  and  the  characters  mentioned  above. 

Treatment.  Transient  epidermization  can  gen- 
erally be  (luickly  obtained  in  small  flat  cutaneous 
carcinomas  by  aseptic  and  antiseptic  dressings.  A 
permanent  healing  is,  however,  not  to  be  obtained 
in  carcinoma  by  this  means,  nor  by  caustic  pastes 
(Vienna  paste,  etc.),  nor  by  treatment  with  X-rays 
or  radium.  Such  healing  is  only  deceptive,  for  the 
cancer  extends  deeply  and  gives  rise  to  metastases; 
hence  the  only  rational  treatment  of  cancerous 
ulcers  is  early  excision  about  one  centimeter  beyond 
the  edge  of  the  ulcer  in  the  healthy  tissue,  and  of 
sufficient  depth.  Infiltration  anaesthesia  should  not 
be  employed,  for  it  obscures  the  limits  of  the  tumor. 
Diseased  glands,  which  can  be  recognized  as  small 
hard  lumps,  should  always  be  removed. 

In  excision  no  regard  must  be  paid  to  adjacent 
parts  (e.g.  eyelids).  The  defect  can  be  remedied  by 
plastic  surgery,  especially  by  DieJJenbacfis  methods. 
Recurrence  seldom  takes  place  in  carcinoma  planum 
after  early  excision. 

Fig.  1.  Shows  a  flat  cutaneous  cancer  in  a  typical 
situation  on  the  face:  still  clear  of  the  subjacent  tis- 
sues. Cured  by  excision,  and  repair  of  the  defect 
by  a  pedunculated  flap  from  the  left  part  of  the 
forehead.  The  defect  in  the  forehead  was  repaired 
by  Thiersch's  grafts. 

Fig.    2.     Advanced   carcinoma   of  the  skin   with 

3 


irregular  borders.  The  growth  has  already  extended 
to  the  bones.  The  upper  eyelid  and  the  ocular  con- 
junctiva are  also  involved.  This  is  a  case  of  the 
rare  form  of  cancer  of  the  skin  first  described  by 
von  Bcrgmann,  which  in  its  early  stages  appears  in 
the  form  of  small  multiple  nodules  and  may  there- 
fore be  mistaken  and  treated  for  tuberculosis  cutis 
(lupus).  The  raised,  irregular,  hard  edges  of  the 
ulcer  point  to  the  correct  diagnosis,  which  in  doubt- 
ful cases  should  be  cleared  up  by  removal  of  a 
piece  for  examination.  Previous  treatment  by  the 
X-rays  had  caused  a  rapid  extension  of  the  carci- 
noma, so  that  the  patient,  on  account  of  the  very 
advanced  local  disease  and  the  severe  cachexia  from 
organic  metastases,  came  to  the  clinic  in  an  inoper- 
able condition.  Treatment  of  inoperable  carcinoma: 
Antiseptic  dressings  with  potassium  permanganate 
and  peroxide  of  hydrogen;   later  on,  cauterization. 

Fig.  4.  Cutaneous  cancer  with  extensive  deep 
growth.  Destruction  of  the  nose,  both  of  the  bony 
framework  and  of  the  ethmoid  cells.  This  form  of 
cancer  in  its  early  stage  consists  of  subcutaneous 
nodules  covered  by  unaltered  skin.  The  skin  gives 
way  when  the  nodules  break  down  and  a  very 
extensive  and  deep  cancerous  ulcer  results.  This 
may  be  mistaken  for  a  gumma,  but  the  latter  is  not 
so  ragged  and  has  a  yellow  core.  (Cf.  Fig.  120.) 
The  presence  of  epithelial  plugs  is  also  characteris- 
tic of  this  form  of  carcinoma.  Microscopical  exam- 
ination and  antisyphilitic  treatment  with  iodide  of 
potassium  will  decide  the  diagnosis  in  doubtful 
cases.  The  papillomatous  forms  (Fig.  4)  which 
often  give  rise  to  deep  cutaneous  cancer,  through 
their  rapid  growth  and  metastatic  formations,  must 
be  regarded  as  extremely  malignant  tumors. 

The  permanent  results  are  generally  favorable 
after  extensive  operations,  which  often  involve  re- 
moval of  diseased  bones  (v.  Bramann,  Grosse). 
When  carcinoma  of  the  face  extends  through  the 


dura  mater,  operation  is  not  indicated,  and  the  case 
must  be  treated  according  to  the  rules  for  inoperable 
cancer.  In  all  extensive  carcinomas  of  the  face  the 
patients  may  die  from  septic  pneumonia  when  the 
destructive  process  reaches  the  buccal  cavity. 

A  special  form  of  cancer  arising  in  the  deep  parts 
of  the  corium  as  cancerous  nodules  constitutes  what 
Krompecher  described  as  basal-celled  cancers.  Ac- 
cording to  Coenen  these  are  not  to  be  classed  with 
endotheliomas,  as  formerly,  for  they  arise  from  the 
basal  cells  of  the  sweat  and  sebaceous  glaud  epithe- 
lium, or  from  the  epithelium  of  the  hair  follic'«s.  In 
distinction  to  the  other  cutaneous  cancers  they  do  not 
become  cornified,  and  were,  therefore,  classed  hy  Borst 
among  the  endotheliomas. 

Multiple  carcinomas  of  the  face  have  been  noted 
by  several  observers  {v.  Bergmann,  Coenen,  Schim- 
melbitsch).  Von  Bergmann,  in  a  case  of  carcinoma 
of  the  forehead,  which  after  some  years  was  followed 
by  another  in  the  floor  of  the  mouth,  was  of  opinion 
that  these  were  separate,  independent  carcinomas, 
because  metastases  in  the  tongue  and  floor  of  the 
mouth  are  very  rare,  and  there  was  a  long  time 
between  the  development  of  the  two  carcinomas. 


Carcinoma  of  the  Mucous 
J  Membranes 

CARCINOMA  LABII  INFERIORIS  (o/  lower  Lip) 

Plate  II,  Fig.  3. 
TUBERCULOSIS  CUTIS  (of  the  Skin) 

Plate  III,  Fig.  5. 
PAPILLOMA   LINGUAE    {of   Tongue) 

Plate  rV",  Fig.  6. 
CARCINOMA  ET  PAPILLOMA  LINGUAE  {of  Tongue) 

Plate  IV.  Fig.  7. 
CARCINOMA  LINGUAE  INCIPIENS 

{Incipient  Carcinoma  of  Tongue) 

Plate  IV.  Fig.  8. 
CARCINOMA  LINGUAE  EXULCERATUM 

{Ulcerating  Carcinoma  of  Tongue) 
LEUKOPLAKIA  {Leukoplakia) 

Plate  IV,  Fig.  9. 

Cancers  of  the  lips  resemble  cancers  of  the  skin 
in  their  form  and  structure,  for  they  are  squamous- 
celled  epitheliomas,  and  tend  to  cornification.  They 
arise  in  the  form  of  cauliflower-shaped,  polypoid 
tumors  on  the  mucous  membrane  of  the  lips,  cheeks, 
and  glans  penis,  or  as  deep  ragged  ulcers  (lips  and 
tongue),  and  appear  in  these  principal  forms  in  all 
mucous  membranes  covered  with  squamous  epithe- 
lium. Carcinoma  of  the  upper  lip  is  very  rare,  but 
V.  Bergmann  has  obsei'ved  a  case  where  a  carci- 
noma of  the  upper  lip  developed  within  a  few  weeks 
after  a  cancer  of  the  lower  lip,  in  a  symmetrical 
position.  Carcinomas  of  the  lower  lip  form  45.6 
per  cent,  of  all  cancers  of  the  face,  nearly  all  occur- 
ring in  the  male  sex.  The  action  of  tobacco  must 
play  a  special  role  in  the  origin  of  cancel:  of  the  lip, 

6 


Bockenheimer,  Atlas. 


'lali. 


U 


CO 


Rebman  Company,  New- York. 


for  the   patients,   of   both   sexes,   are   mostly  great 
smokers. 

Cancer  of  the  lower  lip  often  begins  at  the  junc- 
tion of  the  skin  with  the  red  part  of  the  lip,  generally 
between  the  center  of  the  lip  and  the  angle  of  the 
mouth,  as  a  small,  hard  nodule  at  first  covered  by 
mucous  membrane.  The  mucous  membrane  soon 
becomes  broken  and  the  nodule  grows,  infiltrating 
the  surrounding  tissues  rapidly,  while  the  mucous 
membrane  breaks  down  more  and  more  and  forms 
an  ulcer.  Antecedent  diseases  of  the  mucous  mem- 
brane, such  as  tuberculosis  and  psoriasis  (leuko- 
plakia) appear  to  predispose  to  carcinoma.  The 
whole  of  the  lower  lip  may  be  gradually  destroyed 
(Fig.  3).  Scabs  and  crusts  form  at  several  places  on 
the  ulcer,  and  when  separated  give  rise  to  bleeding. 
While  in  its  early  stages  the  cancerous  ulcer  is  recog- 
nized by  its  hard,  raised  edges  and  crateriform 
floor,  the  advanced  cancer  of  the  lip  shows  papillo- 
matous proliferations  springing  from  the  floor  of  the 
ulcer  (Fig.  3).  The  more  the  carcinoma  extends, 
the  more  it  implicates  the  underlying  bones  and  the 
mucous  membrane  of  the  cheeks  and  floor  of  the 
mouth,  so  that  the  bones  and  the  buccal  mucous 
membrane  may  be  completely  destroyed.  The  exu- 
dation of  growing  cancer  of  the  lip  gives  rise  to  much 
cachexia,  gastritis  and  enteritis,  and  the  secretion 
may  reach  the  lungs  and  cause  death  from  septic 
pneumonia.  In  such  inoperable  forms  the  sub- 
maxillary and  submental  regions  are  usually  filled 
with  hard,  fixed  glands. 

Differential  Diagnosis.  Although  these  ad- 
vanced forms,  which  are  often  neglected,  especially 
in  country  people,  are  unmistakable,  there  may  be 
difficulty  in  the  diagnosis  of  the  early  stage  of  the 
cancerous  ulcer.  The  irregular,  ragged  surface  of 
the  carcinoma  is  in  marked  contrast  to  the  smooth 
surface   of   primary   syphilis,   and   the   comedo-like 

7 


epithelial  plugs  which  are  characteristic  of  all 
squamous-celled  epitheliomas  can  be  extruded  from 
it  by  pressure.  The  glands  are  affected  very  early 
in  carcinoma,  first  in  the  submental  region,  and  are 
usually,  small,  very  hard  and  isolated,  in  contrast  to 
the  multiple  glands  in  primary  syphilis,  which  are 
not  so  hard  and  mostly  situated  at  the  bifurcation  of 
the  carotid. 

Isolated  tuberculosis,  or  an  ulcer  extending  from 
tuberculosis  of  the  buccal  mucous  membrane  or 
tongue,  is  very  rare  on  the  lip.  It  has  in-egular 
edges  which  are  not  so  raised  and  hard  as  those  of 
cancer.  The  surface  of  the  ulcer,  which  results 
from  the  breaking  down  of  small  tubercles,  is  of  a 
reddish-gray  color  and  bleeds  very  easily.  It  is 
usually  covered  with  a  single  large  scab.  No  plugs 
can  be  expressed  from  it.  Glandular  enlargement 
is  soft  and  isolated. 

Ulcerated  cavernoma  (cavernous  angioma)  of  the 
lip  may  have  a  cancerous  appearance,  but  it  usually 
occurs  in  children  and  is  generally  associated  with 
other  anomalies  of  the  blood-vessels. 

The  induration  of  fissures  of  the  lips  resulting 
from  chronic  eczema  heals  quickly  under  rational 
treatment,  and  is  thus  distinguished  from  carcinoma- 
tous induration. 

It  is  important  to  note  that  cancer  of  the  lip  occurs 
not  only  in  old  people  but  also  soon  after  the  thirtieth 
year. 

Treatment.  All  depends  on  early  diagnosis,  for 
the  cuneiform  excision  of  small  tumors  gives  the  best 
chance  of  a  radical  cure.  In  doubtful  cases  excision 
is  to  be  preferred  to  antisyphilitic  or  antitubercu- 
lous  treatment,  so  as  to  lose  no  time.  In  extensive 
growths,  from  one  and  one  half  to  two  centimeters  of 
healthy  tissue  should  be  removed  round  the  tumors, 
and  the  neighboring  parts  suspected  of  disease,  such 
as  bones  and  buccal  mucous  membrane,  should  also 

8 


Bockenheimer,  Atlas. 


Tab.  Ill 


Fie.  5.   Carcinoma  labii  inferioris  —  Tuberculosis  cutis. 


Rebman  Company,  New-York. 


be  removed.  The  defect  can  be  repaired  by  plastic 
operations,  the  best  of  which  are  Dieffcnbach'n  or 
Jacsche's. 

Palpable  glands  should  always  be  removed  by 
separate  incisions  in  the  submental  and  submaxillary 
regions.  The  submaxillary  gland  which  is  often 
affected  is  best  removed  at  the  same  time.  By  radical 
operation  a  permanent  cure  is  possible  even  in 
extensive  carcinomas. 

Fig.  3  shows  a  carcinoma  involving  the  whole 
lower  lip.  Deep  ulcerations  alternate  with  papillo- 
matous outgrowths.  In  some  parts  there  are  scabs 
on  the  surface  of  the  ulcers,  in  others  isolated  yellow 
epithelial  plugs.  The  growth  is  hardly  movable 
over  the  lower  jaw,  and  is  on  the  point  of  extending 
to  the  buccal  mucous  membrane.  After  free  exci- 
sion of  the  tumor,  removal  of  the  enlarged  glands  in 
the  submental  and  submaxillary  regions,  the  exten- 
sive defect  was  repaired  by  double  cheiloplasty 
{DiejfcnhacJi's  operation)  and  a  cure  was  obtained. 

Fig.  5  represents  a  large  cancerous  ulcer,  originat- 
ing from  tuberculosis  of  the  skin,  involving  half  the 
lower  lip.  The  hard,  raised  edges  of  the  ulcer 
divested  of  mucous  membrane  are  characteristic. 
The  floor  of  the  ulcer  is  irregular  and  ragged  and 
beset  with  yellowish  epithelial  plugs.  Cancerous 
ulcers  arising  on  the  basis  of  tuberculosis  of  the 
skin  have  a  great  tendency  to  bleed.  In  contrast  to 
the  forms  of  hypertrophic  lupus,  which  gives  rise  to 
soft,  fungoid,  slow-growing  tumors,  the  hardness 
and  rapid  growth  of  the  lupus-carcinoma  is  charac- 
teristic. Excision  of  the  carcinoma,  removal  of  the 
glands,  and  repair  of  the  defect  by  DiefJenbacWs 
cheiloplasty  led  to  a  cure. 

Fig.  5  also  shows  a  characteristic  picture  of  differ- 
ent forms  of  cutaneous  tuberculosis;  lupus  of  the 
face.  The  disease  appears  most  frequently  in  this 
situation  and  usually  begins  on  the  nose  (tuberculosis 

9 


.of  the  nasal  mucosa),  and  extends  over  the  face  in 
the  form  of  a  butterfly.  The  sharp,  irregular  outline 
on  the  forehead,  neck,  and  behind  the  ears  is  charac- 
teristic. The  disease  begins  with  small  reddish- 
brown  nodules  situated  in  the  cutis  giving  rise  to 
exfoliation  of  the  epidermis  (lupus  exfoliativa) ; 
these  become  confluent  and  form  flat,  reddish-gray, 
easily  bleeding  ulcers  (lupus  exulcerans,  which  after 
healing  leave  radiating  cicatrices,  often  after  consid- 
erable destruction  of  tissue.  (Fig.  5,  ear.)  After  a 
time  papillomatous  proliferations  may  arise  of  soft 
and  spongy  consistence,  especially  about  the  ear 
(lupus  hypertrophicus).  These  three  forms  are  usu- 
ally present  in  the  same  patient  (v.  Bergmann). 

Treatment.  In  circumscribed  forms  excision  of 
the  skin  with  the  diseased  subcutaneous  tissue  is 
indicated,  with  repair  of  the  defect  by  skin  flaps. 
The  diffuse  forms  are  treated  in  v.  Bergmanii's  clinic 
by  the  sharp  spoon  {Volkmann).  The  diseased  parts 
are  scraped  and  the  bleeding  surface  treated  with 
Pacqueli7i's  cautery  or  with  hot  air.  Many  sittings 
are  often  necessary  in  order  to  arrest  the  disease, 
and  the  patients  often  succumb  from  tuberculous 
disease  of  the  internal  organs,  or  relapsing  facial 
erysipelas. 

Cancer  of  the  buccal  cavity  occurs  on  the  tongue, 
the  floor  of  the  mouth  and  the  cheek.  Cancer  of  the 
tongue  (Figs.  7,  8  and  9)  occurs  almost  exclusively 
in  man  (after  the  fortieth  year),  owing  to  the  action 
of  tobacco  and  alcohol.  Antecedent  lingual  or  buc- 
cal leucoplakia  predisposes  to  buccal  carcinoma; 
V.  Bergmann  finds  it  present  in  fifty  per  cent,  of  his 
cases  of  cancer  of  the  tongue.  Leucoplakia  forms 
hard,  white,  opaline  patches  raised  above  the  surface 
of  the  mucous  membrane  of  the  tongue,  consisting  of 
horny  epithelium  (hyperkeratosis).  The  surface,  at 
first  smooth,  after  a  time  becomes  fissured,  especially 
after  excessive  smoking,  and  the  patches  of  leuco- 

10 


Bockenheinier,  Atlas. 


lab.  IV. 


Fig.  6.    Papilloma  linouae. 


Fig.  7.    Carcinoma  et  Papilloma  linguae. 


Fig.  8.    Carcinoma  linguae  incipiens.  Fig.  9.    Carcinoma  linguae  cxiilccratum.        I.euixoplakia. 


Rcbman  Company,  Ncw-\ork. 


plakia  become  clearly  visible  and  at  the  same  time 
take  on  deeper  growth.  Since  carcinoma  arises 
directly  from  these  fissured  patches  of  leucoplakia, 
which  have  absolutely  nothing  to  do  with  syphilis,* 
removal  of  such  large  and  fissured  nodules  should 
always  be  performed,  especially  as  multiple  carci- 
nomas of  the  buccal  cavity  have  been  observed  under 
them.  Microscopically,  the  direct  transition  from 
hyperkeratosis  to  carcinoma  has  not  yet  been  con- 
clusively demonstrated. 

Besides  leucoplakia,  jagged  carious  molar  teeth 
also  act  as  exciting  causes  of  cancer  of  the  tongue, 
which  explains  the  almost  exclusive  occurrence  of 
cancer  in  the  posterior  part  of  the  side  of  the  tongue. 

The  carcinoma  appears  in  two  forms,  according 
as  it  arises  from  the  superficial  mucous  membi'ane  or 
from  the  glandular  epithelium. 

The  first  form  resembles  the  flat  cutaneous  car- 
cinoma and  soon  gives  rise  to  a  small  ulcer  with 
hard,  raised  edges  (Fig.  7,  right  half)  the  fissured  sur- 
face of  which  has  a  yellowish  or  dirty-brown  appear- 
ance. Although  the  carcinoma  is  only  superficial, 
the  submaxillary  glands  are  soon  affected,  owing  to 
the  abundant  lymphatics  of  the  tongue  (Kuttner). 

The  deep  carcinomas  form  hard  nodules  over 
which  the  mucous  membrane  remains  intact  for  a 
long  time.  After  breaking  down  of  the  nodules  and 
destruction  of  the  mucous  membrane,  an  extensive 
crateriform  ulcer  is  formed  with  hard,  irregular  edges 
and  deep  fissures  in  the  center.  This  often  extends 
as  far  back  as  the  epiglottis.  Numerous  epithelial 
plugs  can  be  expressed  from  the  floor  of  the  ulcer, 
and  often  from  the  papillomatous  proliferations. 

*  Translator's  Note — ^This  statement  is  not  in  accordance 
with  the  teaching  of  Foumier  and  the  majority  of  syphilologists, 
who  regard  buccal  leucoplakia  as  almost  exclusively  of  syphilitic  origin. 
According  to  Foumier,  cancer  of  the  tongue  is  due  to  the  combined 
effect  of  syphilis  and  tobacco.  (See  Foumier's  Treatment  and  Pro- 
phylaxis of  Syphihs,  Rebman  Company,  New  York.) 

11 


The  patients  suffer  great  pain  from  the  irritation 
of  free  nerve-endings  in  the  floor  of  the  ichorous 
ulcer,  and,  in  untreated  eases,  succumb  usually 
within  a  year  from  glandular  metastases  extending 
along  the  carotid  to  the  supra-clavicular  region 
(Fig.  9).  Early  diagnosis  is,  therefore,  of  the  great- 
est possible  importance. 

Differential  Diagnosis.  The  superficial  carci- 
noma (Fig.  7)  is  recognized  by  the  characteristic 
features  of  flat  cutaneous  carcinoma  and  differs 
from  s^^hilitic  chancre  by  its  sharp,  hard  edges,  the 
irregular  floor  of  the  ulcer  with  epithelial  plugs,  and 
the  small,  hard  glands.  As  long  as  the  flat  carci- 
noma of  the  tongue  is  covered  with  mucous  mem- 
brane it  may  in  its  earliest  stages  be  confounded  with 
papilloma  (Fig.  6),  especially  in  the  rare  cases  where 
it  lies  more  in  the  center  of  the  dorsal  surface  of  the 
tongue.  Papillomas,  however,  generally  appear  as 
multiple,  soft  elevations  the  size  of  a  pin's  head,  so 
that  the  surface  of  the  tongue  may  appear  furnished 
with  small  points,  or  may  assume  a  lobulated  form; 
or  there  may  be  fungiform  sessile  tumors,  like  stal- 
actites, which  often  form  high  projections  and  have 
a  warty  appearance  (Fig.  7).  That  a  flat  carcinoma 
and  a  papilloma  of  this  kind  may  occur  independ- 
ently without  microscopic  transition  into  each  other 
is  shown  by  v.  Bergmanrts  case  ("Handbook  of 
Practical  Surgery',  III  edition:  Text-book  of  Sur- 
gery, II  edition").  Small  papillomata  cause  the 
patient  hardly  any  inconvenience  and  can  be  re- 
moved with  the  sharp  spoon  or  Pacquelhi  s  cautery. 
Larger  papillomata  should  be  excised  (Fig.  7,  left 
half). 

The  diagnosis  is  difficult  when,  as  in  Fig.  8,  a 
hard,  carcinomatous  nodule  develops  under  a  patch 
of  leucoplakia.  The  irregular,  deep,  hard  infiltra- 
tion and  the  rapid  growth  point  to  a  commencing  new 
growth,  which  should  always  be  removed  before  it 

12 


breaks  through,  especially  when  there  is  leucoplakia 
over  the  nodule. 

Abscesses  of  the  tongue,  which  result  from 
injury  by  foreign  bodies  (steel  pens,  etc.),  and 
form  hard  nodules  in  the  substance  of  the  tongue, 
are  characterized  by  the  early  painfulness  on 
pressure.  Actinomycosis  causes  a  more  diffuse, 
wooden  infiltration  of  the  whole  tongue  and  very 
soon  interferes  with  its  motion.  (Abscess  is  treated 
by  incision  and  actinomycosis  by  incision  and 
scraping). 

The  small  carcinomatous  ulcer  of  the  edge  of  the 
tongue  is  liable  to  be  confounded  with  ulcerations 
caused  by  the  irritation  of  broken  teeth  (dental 
ulcers),  especially  when  it  is  situated  opposite  a 
sharp  tooth;  however,  the  cancerous  ulcer  con- 
tinues to  grow  after  removal  of  the  offending  tooth. 
Larger  ulcerations  which  result  from  the  breaking 
down  of  deep  carcinoma  may  be  confounded  with 
gumma  on  superficial  examination.  The  latter, 
however,  is  almost  always  situated  in  the  center  of 
the  tongue  or  in  its  anterior  part,  and  has  the  charac- 
teristic dirty-yellow,  gummatous  core,  which  can  be 
removed  without  bleeding  (Fig.  119),  in  distinction 
to  the  easily  bleeding  reddish-brown  proliferations  of 
carcinoma.  Moreover,  the  pain  radiating  to  the  ear 
which  is  constantly  present  in  large  carcinomas,  is 
absent  in  gumma;  also  the  glandular  metastases 
and  the  leucoplakia. 

The  clinical  picture  of  carcinoma  is,  therefore,  so 
clear  that  antisyphilitic  treatment  for  the  purpose  of 
diagnosis  is  not  necessary.  Excision  for  diagnosis, 
which  is  often  inconclusive,  is  also  to  be  disregarded 
(v.  Bergmann).  In  cases  where  the  diagnosis  hesi- 
tates between  carcinoma  and  the  rarely  occurring 
isolated  tuberculosis,  or  between  the  still  rarer 
sarcoma  which  is  observed  in  young  people  at  the 
tip  of  the  tongue,  complete  excision  should  always 
be  performed. 

13 


Treatment.  Small  carcinomas  can  be  excised 
and  the  wound  closed,  after  compression  of  the  tongue 
by  a  ligature.  Excision  by  Pacquelin's  cautery  and 
subsequent  plugging  may  also  be  done. 

For  large  carcinoma  a  radical  operation  by  section 
of  the  lower  jaw  is  necessary  (according  to  Sedilloi 
and  Kocher  in  the  middle  line;  according  to  v, 
Bergmann  and  Langenbeck,  laterally)  with  subse- 
quent ligation  of  the  lingual  artery  (cf.  Bocken- 
heimer  &  Frohse's  "Atlas  of  Typical  Operations").* 
By  this  means  not  only  can  the  tumor  of  the  tongue 
be  excised  through  healthy  tissues  as  far  as  the 
epiglottis,  but  also  the  masses  of  glands  which  ex- 
tend from  the  submaxillary  region  to  the  ear  can 
be  removed.  Even  after  extirpation  of  extensive 
portions  of  the  tongue  the  patients,  after  a  few 
months,  can  make  themselves  well  understood. 
Permanent  cures,  are  however,  unfortunately  rare, 
even  after  radical  operations,  in  progressive  cases  of 
cancer  of  the  tongue,  especially  when  the  lower 
jaw  is  involved  and  the  glands  have  become  fixed, 
so  that  some  surgeons  content  themselves  with  the 
local  treatment  of  carcinoma  by  caustics  and  cauter- 
ization. 

The  treatment  of  cancer  of  the  buccal  cavity, 
which  often  arises  on  the  basis  of  leucoplakia,  in  the 
same  form  and  with  the  same  symptoms,  is  carried 
out  on  the  same  principles. 

Fig.  6  represents  a  flat  papilloma  of  the  tongue 
which  was  removed  with  the  sharp  spoon. 

Fig.  7  shows  on  the  right  half  of  the  tongue  a 
superficially  ulcerated  carcinoma,  while  on  the  left 
half  of  the  tongue  there  is  an  extensive  papilloma. 
Both  growths  were  removed  by  excision. 

Fig.  8  shows  a  deep  carcinoma  developing  under  a 
patch  of  leucoplakia;  it  is  not  yet  ulcerated  and  is 
characterized  by  its  hardness  and  irregular  outline. 
This  is  exceptional  in  the  center  of  the  tongue.     The 

^Rebman  Company,  New  York. 

14 


growth   was   removed   by   excision   and   subsequent 
suture. 

Fig.  9  represents  the  most  common  form  of  cancer 
of  the  tongue;  a  carcinomatous  ulcer  of  the  side 
of  the  tongue  with  extensive  destruction,  leucopla- 
kia  and  ghuidular  metastases.  After  section  of 
the  lower  jaw  the  growth  was  widely  removed, 
the  stump  of  the  tongue  sutured  and  the  glands 
removed  from  the  neck. 


15 


Glandular   Carcinoma 


CARCINOMA  MAMMAE  (of  Breast) 
LYMPHOMATA   CARCINOMATOSA  {Carcinomatous) 

Plate  V.  Fig.  10. 
CARCINOMA  MAMMAE  EXULCERATUM 

{Ulcerating  Carcinovia  of  Breast) 
Plate  VI,  Fig.  11. 
CARCINOMA  MAMMILLAE  {of  Nipple) 

Plate  VII,  Fig.  12. 
CARCINOMA   MAMMAE    (of  Breast)— PAGETS  DIS- 
EASE—ECZEMA   CHRONICUM    MAMMILLAE 

(Chronic  Eczema  of  Nipple) 
Plate  VIII,  Fig.  13. 
CARCINOMA  MAMMAE— DISSEMINATIONES 

(Disseminated  Carcinoma  of  Breast) 
Plate  IX,  Fig.  14. 
CARCINOMA  MAMMAE  UTRIUSQUE(o/  both  Breasts) 
—"CANCER  EN  CUIRASSE" 
Plate  X,  Fig.  15. 
CARCINOMA  MAMMAE  (of  i?rfo*0— LYMPHANGITIS 
CARCINOMATOSA    (Carcinomatous  Lymphangitis) 
Plate  XI,  Fig.  16. 

Of  the  carcinomas  of  glandular  organs  those  of 
the  female  mammary  gland  are  among  the  most 
common  (they  take  the  third  place).  They  show  a 
typical  unrestricted  epithelial  proliferation  in  their 
origin  and  development.  Observations  made  on 
cancer  of  the  breast,  therefore,  have  manifold  bear- 
ings on  carcinoma  of  other  organs.  A  division  into 
soft,  many-celled,  rapidly  growing  tumors  of  which 
the  medullary  cancers  represent  the  most  malignant, 
and  slow-growing  scirrhous  forms  with  few  cells,  is 
of  clinical  importance. 

The  exciting  causes  include  inflammatory  irrita- 
tion, puerperal  interstitial  mastitis,  eczema  of  the 
nipple,   antecedent   benign   tumors    (fibro-adenoma, 

16 


Bockcnheimer,  Atlas. 


Tab.  V. 


Fi^.  10.    Carcinoma  inainiiiac  —  L}-mph()mata  carciiiomatosa. 


Bockenheimer,  Atlas. 


Tab.  VI. 


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t/. 


Ktbman  Company,  New-York. 


cysts)  injuries,  mechanical  irritation,  frequent  par- 
turition with  prolonged  suckling  ot"  infants.  Cancer 
of  the  breast  is  attributed  by  the  public  to  injuries 
(blows),  but  these  are  often  too  recent  to  be  accepted 
as  an  etiological  factor,  considering  the  slow  growth 
of  the  carcinoma. 

It  is  a  remarkable  fact  that  of  sterile  women  only 
10  per  cent,  have  cancer  of  the  breast.  In  10  per 
cent,  of  the  cases  there  is  said  to  be  a  hereditary 
tendency. 

Women  are  most  often  affected  at  the  menopause 
(fortieth  to  fifty-fifth  years),  and  come  to  the  sui'geon 
with  nodules  in  the  breast  which  have  been  hitherto 
painless  and  are  only  accidentally  observed.  These 
nodules  very  soon  form  a  malignant  growth  of 
hard  consistency  and  irregular  surface.  The  most 
important  sign  of  a  malignant  new  growth  is  the 
absence  of  any  demarcation  or  encapsulation.  The 
tumor  cannot,  like  all  benign  tumors,  be  separated 
from  the  mammary  tissue  and  moved  freely,  but  is 
fixed  immovably  in  the  glandular  tissue,  with  ill- 
defined  boundaries,  and  is  anchored  in  the  meshes 
of  the  mammary  tissue  by  numerous  offshoots. 
The  nodules,  which  at  first  appear  harmless,  thus 
soon  show  their  malignity.  ^Accompanied  by  lan- 
cinating pains  in  the  thorax,  upper  arm  and  shoulder, 
the  tumor  sends  its  destructive  offshoots  in  all  direc- 
tions into  the  neighboring  tissues,  without  limit  or 
restraint,  and  reaching  the  surface  adheres  to  the 
skin  and  causes  retraction  and  fixation  of  the  nip- 
ple. Finally,  it  gives  rise  to  a  hard  inflammatory 
infiltration  of  the  whole  of  the  overlying  skin.  At  the 
same  time  the  tumor  extends  deeply  and  soon  infil- 
trates the  lymphatics  beneath  the  pectoralis  major 
muscle  and  also  the  regional  lymphatic  vessels  and 
glands  of  the  axilla  (Fig.  10),  which  are  usually 
affected  about  a  year  after  the  formation  of  the 
nodules  in  the  breast,  and  take  the  form  of  hard, 
solid,  painless  nodules,  which  are  often  difficult  to 

17 


feel  in  corpulent  women.  Extensive  glandular  af- 
fection gives  rise  to  radiating  pain  and  oedema  of  the 
arm  (supra-clavicular  glands).  Although  the  cancer 
usually  arises  as  a  single  nodule,  there  are  cases  in 
which  several  nodules  develop  simultaneously  (Fig. 
10)  and  extend  through  the  whole  breast  to  the 
axilla  (Fig.  10).  The  prognosis  is  unfavorable  in 
these  cases,  and  in  disease  of  both  breasts  (Fig.  15). 

The  disease  is  very  frequently  situated  in  the  up- 
per and  outer  quadrant  of  the  breast,  especially  on 
the  left  side.  The  tumors  situated  in  the  outer  half 
of  the  mamma  towards  the  axilla,  wrongly  called 
paramammary  carcinomas,  are  really  glandular  can- 
cers, for  they  originate  in  the  offshoots  of  the  mamma 
which  extend  towards  the  clavicle,  sternum,  axilla 
and  twelfth  rib  in  the  form  of  long,  thin  cords. 

Cancer  of  the  breast,  like  all  cancers  rich  in  cells 
(acinous,  tubular),  grows  rapidly,  especially  during 
pregnancy,  and  causes  destruction  of  the  skin.  A 
cancerous  ulcer  results,  characterized  like  cutaneous 
carcinoma  by  its  hard,  raised,  fixed  borders,  crateri- 
form  base  and  sanious  discharge.  A  hard  infiltra- 
tion develops  round  the  tumor  which  is  usually  fixed 
to  the  thorax.  Small  nodular  thickenings  of  the  ad- 
jacent unbroken  skin  sometimes  constitute  the  first 
sign  of  commencing  general  cutaneous  dissemination 
(Fig.  11).  In  this  way  the  whole  mamma  may  be 
transformed  into  a  large  ulcer  (Fig.  15). 

In  other  cases  a  tumor  is  gradually  developed 
involving  the  whole  breast  without  breaking  through 
externally.  The  skin,  however,  may  be  infiltrated 
and  the  redress  may  be  mistaken  for  inflammatory 
infiltration  (Figs.  14  and  16).  These  leathery  infil- 
trating forms  of  breast  cancer  finally  envelop  the 
whole  mammary  region  like  a  cuirass  (Fig.  15). 

In  the  infiltrated  skin  these  often  appear  small, 
pin-point  disseminations  of  the  carcinoma  (Fig.  15, 
right  side),  which  by  confluence  give  rise  to  a  nodu- 
lar infiltration  of  the  whole  thorax  (Fig.  14). 

18 


Bockenheimer,  Atlas. 


Tab.  VII. 


PifT.  12.    Carcinoma  mammillae. 


Kcbnan  Company,  New-York. 


In  cancers  which  are  poor  in  cells  (scirrhous)  the 
mammary  gland  is  often  diminished  in  size  by 
shrinking,  and  the  skin  becomes  puckered  over  the 
tumor  by  cicatricial  contraction  (Fig.  10). 

Differential  Diagnosis.  Ulcerated  cancers  of 
the  breast  and  those  with  hard,  raised  infiltration 
are  difficult  to  mistake,  but  small  tumors  in  the  sub- 
stance of  the  breast  have  to  be  diagnosed  from  inter- 
stitial mastitis,  benign  tumors  (fibro-adenomas,  cysts 
and  mixed  tumors)  and  abscesses,  in  which  there  is 
frequently  deceptive  induration.  The  age  of  the  pa- 
tient, the  continuous  growth  of  the  nodules,  the 
appearance  of  hard,  lymphatic  glands  in  the  axilla, 
and  the  frequent  occurrence  of  emaciation  and 
cachexia  even  in  small  cancers  assist  in  the  diagnosis, 
which  in  doubtful  cases  can  be  established  by  exci- 
sion of  a  piece  for  examination.  Sarcoma  occurs  at 
an  earlier  age  in  the  form  of  soft  tumors  extending 
to  the  skin,  and  presents  a  fairly  typical  clinical  pic- 
ture which  should  not  be  confounded  with  carcinoma 
(Figs.  29  and  30).  The  glands  are  generally  unaf- 
fected in  sarcoma. 

Treatment.  Radical  excision  of  the  whole  breast 
and  its  processes  as  early  as  possible,  with  removal 
of  the  pectoralis  major  and  in  some  cases  also 
the  pectoralis  minor,  and  complete  removal  of  the 
axillary  glands  is  necessary  for  a  permanent  cure. 
In  V.  Bergmann's  clinic  there  were  29.79  per  cent, 
permanent  cures  out  of  1,000  cases,  i.e.  free  from 
recurrence  three  years  after  the  operation.  Recur- 
rence is  much  less  common  in  the  axillary  glands 
than  locally.  If  of  small  extent  they  can  be  treated 
by  excision,  if  larger  by  the  X-rays  (Fig.  15). 

All  cases  with  extensive  dissemination  in  the  skin 
(Fig.  14),  diffuse  infiltrating  cancer,  "cancer  en 
cuirasse"  (Figs.  15    and  16)  are  unsuitable  for  opera- 

19 


tion.  In  cases  where  the  supra-clavicular  glands  are 
extensively  affected,  permanent  cures  are  hardly  ever 
obtained,  even  after  radical  operations  including  sec- 
tion of  the  clavicle  and  ligation  of  the  axillary  vein;  so 
that  it  is  best  to  abandon  the  operation.  Also  tumors 
which  are  adherent  to  the  ribs,  and  fixed  glandular 
tumors  extending  to  the  axilla  are  unsuitable  for 
operation,  for  the  recurrence  generally  takes  place 
before  the  patient  has  recovered  from  the  operation. 
Operation  is  also  contra-indicated  in  cases  of  severe 
cachexia,  in  the  atrophic  slow-growing  forms  met 
with  in  old  people,  in  cases  with  metastatic  growths 
in  the  lung,  liver  and  bones  (often  leading  to  sponta- 
neous fracture  of  the  neck  of  the  femur.) 

In  the  region  of  the  head  metastatic  carcinomas  are 
sometimes  inoperable.  Owing  to  their  circumscribed 
encapsuled  formation  with  soft  contents  they  may  be 
confounded  with  atheromatous  cysts.  According  to 
Schimvielbusch  they  arise  in  this  form  through  em- 
bolism of  cancer  cells,  and  thus  form  encapsuled 
freely  movable  nodules. 

[The  first  brain  tumor  operated  upon  was  an  en- 
capsulated metastatic  carcinoma  resulting  from  a 
mammary  cancer.] 

In  cases  of  inoperable  carcinoma  the  X-rays  may 
lead  to  epidermization,  especially  in  the  ulcerated 
forms,  after  previous  removal  of  the  ulcerated  parts. 
In  discharging  cancers  powdered  charcoal  or  chlo- 
ride of  zinc  may  be  used  locally,  and  high  doses  of 
morphia  internally. 

Cases  hitherto  reported  as  cured  by  X-rays  are 
fallacious.  No  doubt  a  carcinomatous  nodule  may 
disintegrate  and  disappear  under  the  action  of  the 
X-rays,  but  there  is  always  a  further  growth  in  other 
parts — glands  and  internal  organs.  As  regards  cas- 
tration for  advanced  mammary  carcinoma  in  women, 
further  experience  is  required. 

Doyen's  serum  treatment  of  cancer  has  so  far  given 
no  results. 

20 


Fig.  10  shows  an  acinous  carcinoma  forming  sev- 
eral nodules  in  the  breast,  already  infiltrating  the 
skin.  The  axillary  glands  form  hard,  fixed,  indolent 
nodular  swellings,  and  nodules  can  be  easily  traced 
in  the  form  of  a  rosary  from  the  mammary  gland  to 
the  axilla.  The  nipple  is  retracted  and  fixed,  and 
the  whole  breast  is  diminished  in  size.  Operation 
was  performed  in  the  usual  way.  The  patient  was 
already  emaciated. 

Fig.  11.  A  single  cancerous  nodule  in  a  male 
breast.  The  skin  has  broken  down  and  shows  a 
cancerous  ulcer  with  hard,  raised,  jagged  edges, 
which  has  destroyed  the  nipple.  The  floor  of  the 
ulcer  is  irregular  and  the  whole  tumor  is  fixed  to  the 
pectoral  muscle.  At  the  edge  of  the  ulcer  the  skin 
is  radially  contracted  and  shows  isolated  cancerous 
nodules.  The  axillary  glands  are  hard,  visible  and 
hardly  movable.  In  spite  of  the  small  size  of  the 
tumor  there  was  already  cachexia.  After  removal  of 
the  mamma  with  the  pectoralis  major  and  the  axil- 
lary glands  the  wound,  which  could  not  be  com- 
pletely closed  by  suture,  was  repaired  by  Thiersch's 
grafts. 

Cancer  of  the  male  breast  (about  1  per  cent,  of  all 
mammary  carcinomas  according  to  Schuchardt)  gen- 
erally arises  as  a  small,  hard  nodule  (scirrhous)  in  the 
neighborhood  of  the  nipple  and  giv'es  rise  to  a  typical 
cancerous  ulcer.  The  tumor  occurs  between  the 
fortieth  and  seventieth  years.  Heredity  appears  to 
be  frequent.  Occasionally  cancer  of  the  breast  is 
seen  in  husband  and  wife. 

Fig.  12  shows  a  very  rare  case  of  carcinoma  arising 
from  the  nipple  (squamous-celled  epithelioma).  This 
is  more  common  in  men  than  in  women.  It  com- 
mences as  a  hard  infiltration  of  the  nipple,  in  the 
same  way  as  commencing  carcinoma  of  the  navel. 
The  nipple  is  much  retracted  and  the  whole  areola 
is  transformed  into  a  rigid  wall.  A  cancerous  ulcer 
soon   develops   which   destroys  the  nipple   and   the 

21 


whole    areola.       At    first    there    is    no    connection 
between  this  cutaneous  cancer  and  the  mammary 


gland. 


The  treatment  consists  in  early  extirpation  of  the 
mammilla  with  the  subjacent  mammary  tissue,  by 
means  of  an  oval  incision  with  subsequent  suture. 
Recurrence  is  rare  after  early  treatment.  In  doubt- 
ful cases  with  induration  of  the  mammilla  excision 
should  always  be  performed. 

Fig.  13.  Paget's  disease,  or  chronic  eczema  of 
the  nipple,  which  is  refractory  to  all  treatment.  The 
eczema  begins  on  the  nipple,  gradually  extends  to 
the  areola  and  surrounding  skin  and  assumes  the 
form  of  eczema  madidans  pustulosum.  Retraction  of 
the  nipple  and  dragging  pains  are  caused  by  the 
presence  of  carcinoma  under  the  nipple  (cylinder- 
epithelioma),  which  at  first  has  no  connection  with 
the  nipple  but  later  on  may  become  attached  to  it. 
The  mammary  gland  in  this  case  shows  hard  infil- 
tration round  a  nodule.  In  the  normal  parts  of  the 
skin  there  are  small  dimples.  Obstinate  eczema  of 
the  nipple  accompanied  by  a  tumor  in  the  breast, 
with  infiltration  of  the  axillary  glands  and  early 
cachexia,  make  the  diagnosis  clear  and  indicate 
removal  of  the  whole  mammary  gland  with  the  axil- 
lary glands.  In  cases  of  chronic  eczema  of  the  nip- 
ple resisting  all  treatment,  excision  of  the  mammilla 
is  advisable.  Out  of  884  cases  of  mammary  carci- 
noma in  V.  Bergvianns  clinic  there  were  only  seven 
typical  cases  of  Paget's  disease.  Two  of  the  author's 
cases  showed  cancer  of  the  mammary  gland  without 
connection  with  the  eczematous  nipple. 

According  to  Scliamhacher  and  Ribbert  this  affec- 
tion is  an  inti"a-epidermoidal  carcinoma  which  gives 
rise  to  secondary  chronic  eczema,  an  hypothesis 
which  does  not  explain  all  cases,  and  is  yet  to  be 
proved  by  microscopic  examination. 

Fig.  14.  This  is  a  case  of  tubular  carcinoma 
(Billroth)   with  cutaneous  dissemination  which  has 

22 


Bockenlieimer,  Atlas. 


Tab.  Vill. 


Fig.  13.     Carcinoma  mammae  —  Paget  Disease  —  Eczema  clironicum  mammillae. 


Rcbman  Company,  New- York. 


Bockenheimer,  Atlas. 


Fitr.  14.    Carcinoma  iiiaiiimae    -  Disseniinatioiies. 


iian  Company,  New-York. 


Bockenheiiner,  Atlas. 


Tab.  \. 


U 


lan    Pnmmrn-      V»w-V'<-.irb 


w 


Bockenheimcr,  Atlas. 


Fig.  16.     Carcinoma  mammae.  -  Lymphangitis  carcinomatosa. 


extended  in  all  directions  and  spread  over  the  thorax. 
The  development  of  nodules  in  the  skin  occurs  early. 
These  appear  at  first  as  punctiform,  bluish,  glisten- 
ing elevations,  which  increase  in  number  and  size 
and  coalesce,  forming  a  kind  of  cuirass  inclosing  the 
thorax  in  a  rigid  mass.  (Cancer  en  cuirasse,  Panzer- 
krebs).     These  cases  are  inoperable. 

Fig.  15.  This  is  a  case  of  inoperable  cancer,  en 
cuirasse,  in  which  both  mammae  are  affected  with 
carcinoma.  On  the  one  side  there  has  been  a  recur- 
rence of  the  growth  in  the  scar  soon  after  operation, 
where  a  soft,  fungous,  easily  bleeding  ulcer  presents 
itself.  In  the  surrounding  skin  there  are  several 
isolated  nodules.  The  left  mammary  gland  is  in- 
volved in  a  hard,  immovable,  carcinomatous  infiltra- 
tion. The  transmigration  of  a  carcinoma  from  one 
side  to  the  other  is  possibly  explained  by  the  per- 
sistence of  congenital  lymphatics. 

Fig.  16.  At  first  sight  this  appears  to  be  a  pyo- 
genic inflammation.  However,  the  bluish  color,  the 
retraction  of  the  nipple,  the  hard,  immovable  breast 
forming  a  large  tumor,  and  the  extensive  metastases 
in  the  axillary  and  supra-clavicular  glands  lead  to  a 
diagnosis  of  carcinoma.  J^olkmcuin  has  named  this 
very  rare  form  of  cancer — mastitis  carcinomatosa. 
That  we  have  here  to  deal  with  an  affection  of  the 
lymphatics  (lymphangitis  carcinomatosa)  is  shown  by 
the  punctiform  red  spots  between  the  two  breasts, 
the  larger  punctiform  or  circular  spots  below  the 
clavicle  and  the  changes  in  the  region  of  the  neck. 
The  latter  is  of  a  blue  color  and  the  seat  of  hard 
infiltration  which  is  not  inflammatory  but  due  to 
plugging  of  the  lymphatics  with  cancer  cells,  and 
consecutive  oedema. 

The  three  last  plates  (Figs.  14,  15  and  16)  show 
the  terrible  effects  of  advanced  cancer  of  the  breast, 
so  that  the  necessity  for  the  earliest  possible  diag- 
nosis and  radical  removal  by  operation  must  once 
more  be  urged. 

23 


Naevus  Carcinoma 

Plate  XII,  Fig.  17. 

ATHEROMA— CARCmOMA  (Sebaceous) 
Plate  XIII,  Fig.  18. 

Fig.  17.  Carcinoma  of  the  scalp  is  very  rare  and 
usually  arises  on  the  basis  of  old  scars,  ulcers,  warts, 
atheroma  (sebaceous  cysts)  and  moles.  Pigmentary 
nsevi,  which  are  congenital  or  appear  soon  after 
birth,  when  they  appear  as  warty  formations,  belong 
to  the  class  of  benign  tumors.  Occurring  over  the 
whole  body,  they  were  included  by  v.  Recklinghausen 
among  diseases  of  nerves.  While  the  growth  of  the 
naevus  ceases  with  the  growth  of  the  body,  changes 
occur  in  later  years  which  may  take  the  form  of 
papilloma,  sarcoma,  carcinoma  or  malignant  melan- 
oma. In  the  case  represented  in  Fig.  17,  a  rapidly 
growing  tumor  arose  from  a  congenital  naevus  in 
the  thirty-seventh  year;  the  cutaneous  covering  soon 
disappeared  and  the  tumor  was  separated  by  deep 
fissures  into  cauliflower  growths.  The  ulcerated  sur- 
face is  covered  with  sanious  secretion,  so  that  macro- 
scopic examination  often  does  not  decide  whether  it 
is  a  case  of  ulcerated  carcinoma  or  sarcoma.  That 
it  is  a  malignant  growth  is  shown  by  the  rapid 
growth  of  the  tumor,  which  in  a  short  time  extends 
over  and  destroys  the  whole  nsevus;  the  early  adhe- 
sion to  the  bones;  the  regional  glandular  metastases 
in  the  form  of  hard,  slightly  movable  nodules  behind 
the  ear,  and  the  cachexia  of  the  patient.  On  account 
of  the  glandular  metastases  which  soon  extend  along 
the  large  vessels  from  the  neck  to  the  supra-clavicular 

24 


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region,  the  case  is  presumed  to  be  a  carcinoma  of  the 
scalp  on  the  basis  of  a  na?vus  (pigmentary  carci- 
noma), but  there  remains  the  possibiHty  that  micro- 
scopic examination  may  show  it  to  be  a  pigmentary 
sarcoma. 

Treatment.  This  consists  in  extirpation  of  the 
tumor  and  the  rest  of  the  naevus,  repair  by  a  plastic 
operation,  and  removal  of  the  diseased  glands.  In 
large  nsevi  of  the  head  and  face  a  portion  of  the 
nsevus  can,  in  some  situations,  be  removed  by  an 
elliptical  incision  and  subsequent  suture  {DieJJen- 
hach).  Owing  to  the  elasticity  of  the  skin  of  the 
head  large  nsevi  can  often  be  removed  without  re- 
pair by  plastic  operation.  As  soon  as  changes  of 
any  kind  appear  in  a  naevus,  especially  in  advanced 
age,  it  is  important  to  remove  it  as  soon  as  possible. 
It  is  best  to  remove  all  pigmentary  nsevi  because 
fatal  malignant  melanomatous  growths  so  often 
develop  even  from  the  smallest  pigmentary  spots. 

Fig.  18.  Along  with  multiple  sebaceous  cysts 
scattered  over  the  whole  scalp,  is  a  carcinoma  origi- 
nating from  one  of  the  cysts.  The  sebaceous  cysts, 
commencing  as  small  yellowish  nodules  in  the  skin, 
slowly  grow  into  large  tumors  with  a  broad  base  and 
smooth  surface.  The  cysts  are  fixed  to  the  skin  but 
easily  movable  over  the  subjacent  bone,  and  have  a 
doughy  consistence  often  resembling  fluctuation.  If 
this  mobility  of  the  cyst  over  the  subjacent  tissues 
ceases  and  the  originally  soft  tumor  becomes  a  hard 
nodule  with  an  irregular  rough  surface,  malignant 
degeneration  is  to  be  suspected;  apart  fi'om  the 
occurrence  of  calcification  in  its  walls,  in  which, 
moreover,  the  spherical  smooth  surface  is  generally 
preserved.  This  suspicion  becomes  a  certainty  when 
the  skin  gives  way  and  there  appears  a  rapidly 
growing  nodular  tumor  characterized  by  multiple 
lobulation  and  secreting  a  fetid  discharge.  These 
carcinomas  resemble   in   many  ways  the  formation 

25 


of  a  discharging  sarcoma  (Fig.  33),  and  often  cause 
severe  pain  owing  to  inflammation  round  the  tumor. 
Cachexia  occurs  early,  and  the  patients  are  usually 
of  advanced  age. 

The  diagnosis  of  carcinoma  depends  on  the  hard 
multiple  glandular  enlargement,  which  affects  the 
whole  nape  of  the  neck.  This  usually  occurs  later 
and  is  not  so  hard  in  sarcoma. 

Treatment.  This  consists  in  extirpation  of  the 
carcinoma,  and  involves  removal  of  part  of  the  exter- 
nal table  of  the  skull  on  account  of  the  tumor  being 
fixed  to  it.  The  extensive  space  left  by  removal  of 
the  tumor  can  be  sutured  after  making  two  long 
lateral  incisions  over  both  ears  and  undermining  of 
the  scalp.  The  spaces  left  by  the  lateral  incisions 
can  be  repaired  by  Thiersch's  grafts.  The  glands  in 
the  nape  of  the  neck  must  also  be  removed. 

On  account  of  the  early  appearance  of  glandular 
metastases  the  excision  of  especially  indurated  seba- 
ceous cysts  is  indicated.  Moreover,  as  there  is 
always  a  possibility  of  malignant  degeneration,  it 
is  advisable  to  remove  every  sebaceous  cyst  by 
dissecting  it  out,  so  as  to  avoid  recurrence. 


26 


Bockenheimer,  Atlas. 


Fio;.  IQ.    Carcinoma  penis  —  Leukoplai<ia. 


Kcbman  Company,  New-York 


Carcinoma  Penis 

Plate  XIII,  Fig.  19. 

Carcinoma  of  the  penis  begins  on  the  glans  or  in 
the  coronary  sulcus  as  a  squamous-celled  epitheli- 
oma, generally  between  the  fiftieth  and  seventieth 
year.  Predisposing  causes  are  congenital  phimosis 
with  preputial  concretions,  leucoplakia  prjepu- 
tialis  (white  glistening  patches  similar  to  leucoplakia 
of  the  tongue  and  cheek),  warts,  long-standing 
tuberculous  and  syphilitic  ulcerations.  Old  fistulae, 
which  occur  especially  in  eunuchs  after  removal  of 
the  scrotum,  testicles  and  pendulous  part  of  the 
penis,  near  the  symphysis  or  perineum,  also  predis- 
pose to  carcinoma. 

The  usual  form  is  that  represented  in  the  figure,  a 
warty  carcinoma  which  destroys  the  prepuce  and 
soon  forms  a  cauliflower  growth.  Between  the  indi- 
vidual hard  nodules  destitute  of  skin  appear  crateri- 
form  excavations  which  are  characteristic.  Epithe- 
lial plugs  can  be  expressed  from  the  growth,  and  in 
other  parts  the  surface  is  cornified.  Thus,  contin- 
uous growth  alternates  with  permanent  disintegra- 
tion. The  rapidly  developing  nodules  often  cause 
exhausting  hemorrhage,  while  the  breaking  down  of 
the  carcinoma  gives  rise  to  a  fetid  sanious  discharge. 
The  borders  of  the  growth  are  hard,  raised  and  promi- 
nent. The  whole  penis  may  be  transformed  into  a 
large  growth  which  may  extend  to  the  scrotum,  testi- 
cles and  pelvis.  The  growth  may  destroy  the  urethra 
and  cause  much  pain  on  micturition. 


A  more  rare  form  of  carcinoma  arises  as  a  small 
ulcer,  generally  on  the  corona  glandis.  It  is  hidden 
by  the  resulting  phimosis,  but  its  characteristic  hard 
borders  can  be  felt  distinctly  and  there  is  a  sanious 
secretion.  The  inguinal  glands  are  affected  early 
and  point  to  the  diagnosis  of  carcinoma.  The 
growth  at  first  causes  the  patient  little  inconvenience, 
but  quickly  leads  to  severe  cachexia,  so  that  the 
patients  often  present  themselves  with  extensive  met- 
astases of  the  inguinal  and  retro-peritoneal  glands, 
and  are  in  an  inoperable  condition.  A  saying  of 
Kauffmann's,  "In  old  men  with  phimosis  and  offen- 
sive discharge  the  possibility  of  cancer  is  always  to 
be  borne  in  mind,"  merits  special  consideration. 

Differential  Diagnosis.  Both  forms  of  carci- 
noma are  so  characteristic  that  they  can  hardly  be 
confounded  with  other  affections.  The  papillo- 
matous form  at  first  sight  suggest  condylomata 
acuminata  when  these  have  coalesced  into  soft 
tumors,  but  in  these  the  borders  are  as  soft  as  the  rest 
of  the  growth.  A  phagedenic  ulcer  may  cause  de- 
struction of  the  glans  penis,  but  the  necrosis  resulting 
from  the  rapid  destruction  differs  from  the  prolif- 
eration of  the  carcinoma,  and  the  phagedenic  ulcer 
soon  heals  after  cauterization.  Syphilitic  chancre 
also  has  hard  borders  like  the  cancerous  ulcer,  but 
its  surface  is  smooth  in  distinction  to  the  ragged  sur- 
face which  is  always  present  even  in  small  cancerous 
ulcers.  Search  may  also  be  made  for  the  Spiro- 
chseta  pallida  of  syphilis. 

Sarcoma  affecting  the  corpus  cavernosum  are  soft 
rapidly  growing  tumors,  and  for  a  long  time  have  no 
glandular  metastases. 

Treatment.  Amputation  of  the  penis  and  re- 
moval of  the  glands  from  both  inguinal  regions. 
The  prognosis  is  favorable  if  the  glands  are  not 
affected  before  operation.     In  cases  where  the  car- 

28 


ciuoma  has  already  affected  the  whole  penis,  testi- 
cles and  prostate,  a  radical  operation  may  be 
attempted  by  temporary  section  of  the  pubis  on 
both  sides  {Bramann,  Lexer,  Manz),  unless  extensive 
glandular  or  organic  metastases  contra-indicate  any 
intervention.  Recurrence  is  frequent  at  the  seat  of 
amputation.  In  inoperable  cases  the  cancerous 
ulcer  can  be  destroyed  with  Pacquelin's  cautery  and 
afterwards  treated  by  X-rays. 


29 


CARCINOMA  CUTIS  EX  COMBUSTIONE  (of  Skin  after  Bum) 
Plate  XIV,  Fig.  20. 

CARCINOMA  CUTIS  EX  VERRUCA  (o/  SUn  after  Wart) 
Plate  XV.  Fig.  21. 

CARCmOMA  CUTIS  EX  CICATRICE  {of  Skin  after  Cicatrix) 
Plate  XV,  Fig.  22. 

Cutaneous  carcinomas  of  the  extremities  are  com- 
paratively rare  and  always  follow  preceding  changes 
or  morbid  conditions  in  the  skin.  Most  frequently 
they  arise  on  the  basis  of  old  scars  of  various  origins, 
especially  from  hypertrophic  keloidal  scars  left  after 
extensive  burns.  Hawkins,  in  1835,  described  car- 
cinomas arising  from  scars  left  after  severe  flogging, 
mostly  in  sailors.  Dietrich  described  a  carcinoma 
originating  in  the  scar  from  osteomyelitis,  which  was 
for  a  long  time  regarded  as  primary  carcinoma  of 
bone.  The  scar  generally  becomes  fissured,  form- 
ing a  small  wound  which  afterwards  becomes  a  car- 
cinomatous ulcer  (Fig.  21)  with  all  its  characteristic 
features,  hard  borders,  papillomatous  proliferations, 
ragged  surface  and  epithelial  plugs.  A  cauliflower 
tumor  grows  which  soon  becomes  fixed  to  the  fascia 
(Figs.  20  and  22). 

Warts,  old-standing  ulcers  of  the  leg  and  lupoid 
changes  in  the  skin  also  lead  to  carcinoma  of  the 
extremities.  Eczema  of  the  skin  occurring  in  chim- 
ney-sweeps and  workers  in  paraffin  has  often  led  to 
multiple  carcinoma  of  the  extremities. 

Fig.  20  shows  a  papillary  carcinoma  of  the  skin 
of  the  leg  arising  from  the  scar  of  a  burn.  The 
smooth,  partly  white  and  partly  brownish,  shiny 
scars  of  the  burn  are  seen  over  the  whole  leg.  The 
carcinoma  has  extended  above  and  below  and  has 

30 


Tab.  .\l\-. 


['I.r   or 


r^nrrinrMnn    rrwrW    i'\    rninhlisi 


Bockeiiheimer,  Atlas. 


Tab.  .W. 


U 


(M 


;/, 


Rebman  Company,  New- York. 


extended  round  the  whole  circumference  of  the  leg. 
The  soft,  cauliflower  proliferations  have  given  rise  to 
severe  hemorrhages.  From  the  depth  of  the  growth 
there  is  a  sanious  discharge.  The  borders  of  the 
tumor  are  very  hard  and  raised,  and  are  immovable 
over  the  fascia.  The  inguinal  glands  were  already 
involved. 

Treatment.  Amputation  through  the  thigh  with 
removal  of  the  inguinal  glands.  In  cases  of  chronic 
ulcer  of  the  leg  with  commencing  carcinoma  in  the 
form  of  hard,  prominent  tumors  in  the  soft  granula- 
tions, it  is  best  to  remove  the  whole  ulcer  as  early  as 
possible. 

Fig.  21  shows  a  carcinoma  in  a  common  situation, 
the  back  of  the  hand,  arising  from  a  wart  and  form- 
ing a  characteristic  cai'cinomatous  ulcer.  As  the 
growth  was  still  movable  over  the  fascia,  and  there 
were  no  glandular  enlargements,  it  was  excised  and 
the  gap  repaired  by  a  pedunculated  flap  from  the  fore- 
arm. The  rapid  growth  of  these  small  tumors  with 
hard  borders  makes  early  diagnosis  and  removal 
necessary,  so  as  to  avoid  recurrence. 

Fig.  22  shows  a  very  extensive  carcinoma  arising 
from  the  scar  of  an  injury  two  years  before.  In  this 
ease  the  irregular,  wall-like,  hard,  irregular  borders 
are  very  marked.  The  floor  of  the  ulcer  is  in  some 
places  cornified  and  is  covered  with  crusts  and 
sanious  secretion.  The  carcinoma  has  already  ex- 
tended through  the  fascia  to  the  bones,  interfering 
with  the  function  of  the  hand.  The  glands  of  the 
elbow  and  axilla  are  hard  and  nodular.  The  rapid 
growth  of  the  tumor  has  led  to  severe  cachexia. 


t> 


Treatment.     Amputation  through  the  arm  and 


removal  of  glands. 


31 


Melanocarcinoma 

Plate  XYI,  Fig.  23. 

The  malignant  melanomas  (melanosarcoma,  mel- 
anoendothelioma  and  the  rarely  occurring  melano- 
carcinoma) occur  most  often  in  the  skin,  also  in  the 
adjacent  mucous  membrane,  and  in  the  choroid  and 
iris.  In  the  skin  they  arise  from  benign  melanomas, 
especially  from  flat  pigmentary  naevi,  and  from 
warts  which  become  continually  irritated.  Warts  on 
the  sole  of  the  foot  and  on  the  fingers  often  give  rise 
to  these  growths.  A  sessile  or  pedunculated  tumor 
develops,  which  is  characterized  by  black,  bluish- 
black  or  brownish-yellow  coloration  (Fig.  23).  The 
skin  soon  becomes  ulcerated,  and  by  the  breaking 
down  of  the  tumor  a  deep  ragged  ulcer  is  produced. 
Melanocarcinomas  are  characterized  by  the  hardness 
of  the  base  of  the  tumor,  thus  differing  from  the  soft, 
easily  bleeding  melanosarcomas  which  rapidly  dis- 
integrate into  a  brownish-black  watery  mass,  and 
form  the  soft,  bleeding  angiosarcomas. 

Melanocarcinoma  of  the  skin  not  only  grows 
deeply  towards  the  fascia,  but  also  forms  early  dis- 
seminations in  the  skin,  in  the  form  of  small  black 
nodules  in  the  neighborhood  of  the  mother  tumor, 
which  form  a  large  growth  by  confluence. 

The  great  malignity  of  these  tumors  is  shown  by 
the  early  appearance  of  metastases  in  the  regional 
lymphatic  glands,  which  generally  form  larger  tumors 
than  the  primary  one;  also  by  the  early  infection  of 
the  lungs,  liver,  heart,  brain,  and  other  organs  by 
metastatic  deposits. 

33 


Bockenheimer,  Atlas. 


Tab.  XVI. 


Fig.  23.    Melanocarcinoina  cutis  ex  verruca. 


Rebman  Company,  New-York. 


Owing  to  the  rapid  development  of  these  metas- 
tases pigmentation  is  usually  absent  in  them. 

Melanocarcinomas  may  be  seen  in  children  as 
multiple  growths  in  the  skin  in  connection  with 
xeroderma  pigmentosum.  The  rapid  growth  and 
frequent  hemorrhages  lead  to  severe  anaemia. 

Treatment.  Small  tumors  of  the  skin  can  be 
widely  removed  with  the  fascia.  In  the  extremities 
the  best  and  most  radical  method  is  amputation  and 
removal  of  the  regional  glands.  In  spite  of  early 
and  extensive  operation  recurrence  is  very  frequent, 
and  in  v.  Bergmann's  clinic  only  one  case  is  known 
to  be  free  from  recurrence  after  a  year.  It  is,  there- 
fore, urgent  to  take  prophylactic  measures  by  excis- 
ing all  pigmentary  nsevi, especially  in  advanced  age, 
and  all  warts  which  become  continually  irritated  or 
inflamed.  The  gap  left  by  removal  of  extensive  pig- 
mentary nsevi  of  the  face  must  be  filled  by  skin 
flaps.  Cauterization  of  ngevi  and  warts  is  to  be 
condemned,  as  the  irritation  may  be  an  exciting 
cause  of  tumor  formation. 

Fig.  23  shows  a  tumor  arising  from  a  pigmentary 
wart;  the  alveolar  structure  on  microscopic  examina- 
tion showed  it  to  be  a  melanotic  carcinoma.  In  spite 
of  amputation  of  the  leg  and  removal  of  the  inguinal 
glands,  death  resulted  from  organic  metastases. 


33 


Sarcoma 

Plates  XMI— XXM. 

LYMPHOSARCOMA  COLLI   {of  Xeck) 

Plate  XVII.  Fig.  '24. 
SARCOMA   EPIPHARYNGEALE   (Epipharyngeal  Sarcoma) 
POLYPOSIS  NASI   MALIGNA   (MaHgtiont  Nasal  Polypus) 

Plate  XMII,  Fig.  25. 
ANGIOSARCOMA   CUTIS  {of  Skin) 

BOTRIOMYCOSIS 

Plate  XIX.  Fig.  26. 
SARCOMA  FUNGOIDES  ORBITAE 

{Fungating  Sarcoma  of  Orbit) 

Plate  XIX,  Fig.  27. 
MELANOSARCOMA  CUTIS  {of  Skin) 
LYMPHOMATA  SARCOMATOSA  COLLI 

{Sarco7nato7ts  Lymphoma  of  Neck) 

Plate  XX,  Fig.  28. 
SARCOMA  MAMMAE  EXULCERATUM 

{Ulcerating  Sarcoma  of  Breast) 

Plate  XXI.  Fig.  29. 
SARCOMA  MAMMAE   CYSTICUM    {Cystic  Sarcoma  of  Breast) 

Plate  XXII.  Fig.  30. 
SARCOMA  CUTIS   MULTIPLEX    {Multiple  Sarcoma  of  Skin) 

Plate  XXIII.  Fig.  31. 

SARCOMA  HUMERI  PERIPHERICUM 

{Peripheral  Sarcoma  of  Humerus) 

Plate  XXrV",  Fig.  32. 
SARCOMA  FASCLAE  BRACHII  EXULCERATUM 

{Ulcerating  Sarcoma  of  Brachial  fascia) 

Plate  XXV.  Fig.  33. 
CHONDROMYXOSARCOMA   GENUS   {of  Knee) 
EXOSTOSES    MALIGNAE     (Maligyianf  Exostosis) 

Plate  XXM.  Fig.  34. 
SARCOMA  GIGANTOCELLULARE  {Giatd-celled)— EPULIS 

Plate  XXVn,  Fig.  35. 

The  tumors  formerly  called  Sarcoceles  owe  their 
name  to  the  fact  that  they  have  the  appearance  of 
fleshy   masses   on    section.    In   distinction   to   carci- 

34 


nomas  the  sarcomas  develop  from  the  various 
connective  tissue  elements,  with  the  exception  of 
endothelium,  and  may,  therefore,  arise  in  the  skin, 
subcutaneous  tissue,  fascia,  periosteum,  bone,  nerves, 
and  in  the  connective  tissue  of  all  other  organs. 
Owing  to  the  often  very  rapid  growth  the  newly 
formed  cells  do  not  attain  complete  maturity,  so 
that  the  sarcoma  consists  of  imperfectly  developed 
connective  tissue.  In  its  early  stages  it  often  re- 
sembles, microscopically,  inflammatory  granulation 
tissue,  but  by  its  rapid  growth  it  soon  assumes  the 
appearance  of  a  malignant  tumor.  The  bulk  of  the 
sarcoma  is  formed  of  various  connective  tissue  cells, 
while  the  interstitial  fibrous  tissue  is  scanty.  The 
abundant  formation  of  new  blood-vessels  is  char- 
acteristic of  sarcoma. 

The  transition  of  fibromas,  especially  those  which 
arise  from  the  connective  tissue  of  fascia,  and  of 
other  connective  tissue  tumors  e.g.  chondroma,  into 
sarcoma  has  been  demonstrated. 

Patients  often  attribute  these  growths  to  various 
injuries,  but  there  is  no  direct  proof  of  this. 

The  pure  sarcomas  are  classified  according  to  their 
microscopic  structure  into  round-celled,  spindle- 
celled  and  giant-celled  sarcoma.  Those  formed  of 
various  tissues  are  known  as  lympho-,  myxo-,  fibro-, 
chondro-,  angio-,  and  glio-sarcoma.  The  pigmentary 
or  melanosarcomas  are  placed  in  a  special  group. 

Clinically,  sarcomas  are  best  divided  into  soft, 
many-celled,  quickly  growing,  very  malignant,  easily 
recurring  (medullary  sarcoma,  usually  small  round- 
celled  sarcoma),  and  the  hard,  few-celled,  slow- 
growing,  less  malignant  forms  (spindle-celled  and 
giant-celled  sarcoma).  In  the  first  form  the  soft 
consistence  is  due  to  the  richness  in  cells  and  the 
scanty  development  of  interstitial  tissue.  Compared 
with  carcinomas,  sarcomas  are  more  circumscribed 
and  at  first  almost  completely  encapsuled  tumors, 
with  borders  as  soft  as  the  rest  of  the  tumor. 

35 


Owing  to  frequent  hemorrhages  and  softening  in 
the  interior  of  the  sarcoma  cystic  cavities  are  formed 
which  can  be  recognized  by  the  presence  of  fluctua- 
tion (Figs.  25  and  30).  Sarcomas  situated  under  the 
skin  gradually  destroy  and  break  through  it  and  pro- 
liferate on  the  surface  in  a  variety  of  forms.  Fleshy 
reddish-brown  parts  alternate  with  yellowish-white, 
pulpy  parts  in  these  tumors.  There  are  usually 
blood  extravasations,  both  old  and  recent.  The 
whole  tumor  has  the  appearance  of  a  fungoid  mass 
(Figs.  26,  27,  29  and  33).  After  a  time  these  super- 
ficially proliferating  growths  break  down  and  set  up 
inflammation,  so  that  the  characteristic  appearance 
of  the  sarcoma  is  lost,  and,  on  the  scalp  and  extremi- 
ties, for  example,  it  cannot  be  distinguished  from  a 
discharging  soft  carcinoma.  As  the  sarcoma  usually 
breaks  through  the  skin  and  proliferates  on  the  sur- 
face, so  may  it  extend  into  all  the  deeper  tissues,  so 
that  finally  an  enormous  tumor  is  formed  which  may 
destroy  the  bones  (Figs.  25,  27  and  33). 

The  second  form,  the  slow-growing,  few-celled 
tumors,  resemble  fibromas  and  often  represent  transi- 
tional forms  (fibro-sarcoma).  The  latter  sometimes 
occur  as  multiple  nodules  in  the  skin. 

These  tumors  often  occur  in  robust  people  in  mid- 
dle life  (thirty  to  fifty).  Very  often  sarcoma  is  con- 
genital or  appears  in  infancy  (kidneys  and  testicles), 
also  soon  after  puberty  (mammary  gland).  The 
earlier  the  tumors  appear,  the  more  malignant  they 
are  as  a  rule.  iSIultiple  sarcomas  are  seen  in  the 
skin  as  pigmentary  sarcomas  (Fig.  31)  and  in  the 
bones. 

The  soft  sarcomas  lead  to  metastases  much  more 
often  than  the  hard  forms.  Metastatic  deposits  are 
formed  by  growth  of  the  tumor  into  the  large  veins 
and  the  formation  of  emboli,  which  are  carried  to  the 
lung,  spleen,  liver  and  brain.  Dissemination  by  way 
of  the  lymphatics  is  almost  completely  absent.  The 
latter  are  certainly  often  involved,  especially  in  ulcer- 

36 


ated  sarcoma  and  melanotic  forms;  also  in  sarcoma 
of  bone. 

By  the  entrance  of  the  tumor  cells  into  the  blood 
stream  and  by  the  setting  up  of  inflammatory  pro- 
cesses a  condition  of  fever  is  produced. 

In  many  cases  the  body  is  so  quickly  affected  by 
metastases  that  the  patients  soon  succumb  from 
severe  anaemia.  Unfortunately  patients  often  come 
for  treatment  when  there  are  already  metastases  in 
the  lung  causing  pleural  effusion  and  hemoptysis. 

Differential  Diagnosis.  Sarcoma  differs  from 
carcinoma  in  the  softer  consistence  of  the  tumor  and 
its  regular  surface,  and  from  benign  tumors  by  its 
rapid  growth.  The  distinction  from  syphilitic  pro- 
ducts is  often  difficult  and  sometimes  not  settled  by 
microscopic  examination,  and  according  to  Esmarch 
many  growths  were  formerly  extirpated  as  sarcoma 
which  might  have  been  cured  by  anti-syphilitic  treat- 
ment. 

Treatment.  x\ll  tumors  in  which  there  is  a  sus- 
picion of  sarcoma  should  be  removed  as  early  and 
as  radically  as  possible.  As  the  tumors  are  some- 
times encapsuled,  operation  has  been  unfortunately 
limited  to  enucleation  in  these  cases;  but,  as  in  car- 
cinoma, the  tissue  surrounding  the  tumor,  which  is 
already  infiltrated  by  tumor  cells,  must  be  removed. 
In  cases  of  soft,  rapidly  growing  sarcoma  of  the 
extremities,  the  question  of  amputation  and  even  dis- 
articulation arises.  In  spite  of  operation  recurrence 
is  frequent;  either  locally  or  in  the  form  of  dissem- 
inated nodules,  less  commonly  in  the  form  of  lym- 
phangitis sarcomatosa.  In  the  hard  forms  of 
sarcoma  recurrence  may  also  occur,  in  the  form  of 
soft  growth,  which  is  a  most  unfavorable  sign. 

Inoperable  cases  have  been  treated  with  the  X- 
rays,  but  the  action  is  only  superficial  {Unger,  Schles- 
inger).     By  this  treatment  the  superficial  nodules  are 

37 


destroyed,  just  as  in  intercurrent  erysipelas,  but  the 
tumor  continues  to  grow  in  the  deeper  tissues  and  in 
other  places.  Subcutaneous  injections  of  arsenic 
and  atoxyl  are  worth  a  trial,  and  iodide  of  potas- 
sium in  large  doses  may  be  administered.  Serum 
therapy  has  so  far  given  no  results. 


38 


Bockenheinier,  Atlas. 


Tab.  XVII. 


Fig.  24.     Lyiiipliosarcoma  colli. 


Rcbnun  Company,  New-York. 


LYMPHOSARCOMA  COLLI  {of  Neck) 
Plate  XVII,  Fig.  24. 

Clinically,  the  name  lymphosarcoma  is  best 
applied  to  those  sarcomas  which  originate  in  lym- 
phatic glands,  whether  their  cells  have  the  character 
of  lymph  cells  or  arise  from  the  stroma  of  the  glands. 
This  is  all  the  more  indicated  as  both  forms  of  sar- 
coma can  only  seldom  be  distinguished  from  one 
another,  clinically  or  microscopically.  The  seat  of 
predilection  of  these  tumors  is  the  region  of  the 
neck,  where  the  lymphatics  are  abundant.  A  diffuse 
nodular  tumor  quickly  develops  from  a  group  of 
small,  hard,  movable  glands. 

The  malignancy  of  these  tumors  is  shown,  espe- 
cially in  young  individuals,  by  the  continual  formation 
of  fresh  nodules  at  the  periphery,  which  coalesce  with 
the  main  tumor  and  cause  it  to  attain  a  considerable 
size.  The  unlimited  growth  into  the  neighboring 
tissues  is  characteristic.  The  capsule  of  the  glands 
is  quickly  broken  through,  thus  differing  from  lym- 
phoma. The  cervical  fascia  is  destroyed  and  the 
sterno-mastoid  muscle  invaded.  The  skin  is  at  first 
reddish,  then  bluish  red  or  livid;  it  then  becomes 
thin  and  gives  way  over  the  tumor.  The  exposed 
parts  of  the  tumor  rapidly  break  down  from  inflam- 
mation. The  sarcoma  grows  into  the  deeper  parts, 
especially  into  the  internal  jugular  vein,  giving  rise 
to  fatal  organic  metastases.  The  vagus  nerve  and 
the  common  carotid  also  become  enveloped  and 
destroyed  by  the  tumor.  Dyspnoea  and  dysphagia 
may  be  caused  by  pressure  on  the  larynx  and  esoph- 
agus. The  tumor  extends  downwards  into  the 
mediastinum   and   may  even   destroy  the  vertebrae. 

39 


Lymphosarcoma  is  distinguished  from  other  tumors 
of  the  neck  by  its  rapid  growth  in  all  directions,  its 
breaking  through  to  the  exterior,  and  its  sanious  dis- 
integration. 

The  diagnosis  is  usually  not  established  in  the 
early  stages  as  the  growth  is  hard  and  limited  to  the 
glands;  microscopic  examination  is  also  inconclu- 
sive. 

Differential  Diagnosis.  Malignant  lymphoma 
(Hodgkin's  disease,  pseudoleukjemia)  which  usually 
begins  in  the  neck,  consists  of  small,  multiple,  encap- 
suled  nodules  which  do  not  break  down  nor  extend 
to  the  neighboring  organs.  There  are  generally  also 
glandular  enlargements  in  the  axillae,  groins  and 
mediastinum,  and  changes  in  the  spleen  and  bone- 
marrow. 

Leuksemic  IjTnphoma  can  be  diagnosed  by  the 
blood  changes. 

Tuberculous  glands  are  characterized  by  the  iso- 
lated groups  of  glands  of  different  consistence — hard, 
soft,  or  fluctuating. 

Syphilitic  glands  are  at  first  hard,  later  on  soft; 
but  are  not  so  extensive. 

Branchiogenous  carcinoma  (t\  Volhnann),  arising 
from  the  remains  of  the  epithelium  of  the  branch- 
ial clefts,  is  very  rare  and  appears  as  very  hard, 
spherical  tumors  in  the  carotid  fossa. 

Metastatic  carcinoma  and  sarcoma  can  be  diag- 
nosed by  the  presence  of  the  primary  tumors  (scalp, 
esophagus,  parotid,  maxilla). 

Actinomycosis  may  also  cause  hard  infiltration  of 
the  neck,  but  the  infiltration  is  diffuse  and  uniform, 
not  nodular,  and  extends  over  the  whole  region  of 
the  neck. 

The  tumors  affecting  the  sheaths  of  the  blood- 
vessels, first  described  by  Langenbech,  are  to  be 
regarded  as  lymphosarcomas  which  have  involved 
the  vascular  sheaths  at  an  early  period. 

40 


Treatment.  Extirpation  of  lymphosarcoma  has 
only  a  chance  of  success  by  early  diagnosis,  and  even 
then  recurrence  is  frequent.  For  the  removal  of 
such  extensive  non-encapsuled  tumors  much  inter- 
vention is  necessary,  in  some  cases  including  tem- 
porary ligature  of  the  common  carotid.  As  the 
internal  jugular  vein  and  vagus  nerve  are  usually 
removed  with  the  common  carotid,  with  consequent 
disturbances  (encephalomalacia,  pneumonia),  many 
prefer  internal  treatment  with  high  doses  of  arsenic, 
or  by  the  X-rays,  by  which  means  transient  improve- 
ment may  be  obtained. 

Fig.  24  shows  an  extensive  lymphosarcoma  of  the 
neck.  The  tumor  extends  diffusely  over  the  whole 
of  the  right  side  of  the  neck  and  is  constituted  by 
several  nodular,  irregular  formations.  The  skin  is 
broken  in  one  place,  in  others  it  is  thin  and  of  a 
bluish-red  color.  There  is  a  sanious  discharge  from 
the  fistula.  Pressure  of  the  tumor  on  the  large  ves- 
sels has  caused  severe  cyanosis,  and  pressure  on  the 
recurrent  nerve  hoarseness  and  asph>-xia.  In  spite 
of  treatment  by  arsenic  and  the  X-rays  the  patient 
continued  in  a  state  of  cachexia. 


41 


SARCOMA  EPIPHARYNGEALE  (Epipharyngeal) 
POLYPOSIS  NASI  MALIGNA  (Malignant  Nasal  Polypus) 
Plate  XMII,  Fig.  25. 

In  the  naso-pharynx  two  kinds  of  growths  claim 
special  attention — fibromas,  usually  occurring  in 
males  between  the  twenty-fifth  and  thirtieth  years, 
also  called  naso-pharyngeal  polypi,  arising  from  the 
basilar  process — and  sarcomas,  which  appear  be- 
tween the  thirtieth  and  fiftieth  years.  Langenbeck 
separates  tumors  arising  in  the  spheno-palatine  fossa 
as  retro-maxillary  tumors,  but  after  further  extension 
they  cannot  be  distinguished  from  the  two  mentioned 
above. 

The  fibromas,  occurring  at  the  earlier  age,  gen- 
erally arise  from  the  connective-tissue  cells  of  the 
periosteum  as  pedunculated  or  sessile  encapsuled 
tumors,  which  by  extensive  growth  fill  up  all  the 
spaces  and  apertures  of  the  naso-pharynx,  especially 
the  posterior  nares,  cause  atrophy  of  the  bones  by 
pressure,  and  break  through  into  the  nasal  cavity, 
maxillary  antrum  and  cranial  cavity.  On  account  of 
their  great  vascularity  these  growths,  which  in  some 
places  often  take  the  form  of  cavernous  tumors,  are  of 
much  softer  consistence  than  other  fibromas.  The 
tumors  may  ulcerate  on  the  surface  and  give  rise  to 
exhausting  hemorrhage.  On  account  of  their  ten- 
dency to  increase  and  the  frequent  occurrence  of  sar- 
comatous tissue  in  them,  they  are  to  be  treated  as 
malignant  growths. 

In  older  individuals,  in  the  majority  of  cases,  we 
have  to  do  with  true  sarcomas  arising  from  the 
periosteum  or  fascia  (malignant  naso-pharyngeal 
polypi),   which   extend   to   the   posterior  nares,   the 

42 


Bockeiiliciiiier,  Atlas. 


Tab.  XVIII 


Fig.  25.     Sarcoma  cpipliaryiiscale  -    Polyposis  nasi  maligna. 


lJ..Knii.,     r"«„,«-..,,       \.T..._.    \/. 


/ 


spheno-maxillary  fossa,  Eustachian  tubes  and  larynx; 
not,  however,  as  encapsuled  tumors  hke  the  fibro- 
mas,  but  as  soft,  fungoid,  sessile,  firmly  attached 
growths  with  irregular  boundaries.  Later  on  they 
grow  very  rapidly,  causing  destruction  of  the  neigh- 
boring bones,  and  extend  to  the  surface  through  the 
frontal  sinus,  nasal  cavity  and  orbit,  and  internally 
to  the  brain.     (Figs.  25  and  27). 

Disintegration  of  the  growth  goes  hand  in  hand 
with  the  advancing  growth  and  the  patient  succumbs 
from  the  results  of  hemorrhage,  septic  infection, 
anaemia  and  organic  metastases. 

The  clinical  symptoms  in  fibroma  and  in  com- 
mencing sarcoma  arise  from  obstruction  of  the 
naso-pharynx.  Continually  keeping  the  mouth  open 
suggests  disease  of  the  naso-pharynx.  Owing  to 
obstruction  of  the  posterior  nares  the  patients  snore 
during  sleep;  they  acquire  nasal  catarrh  (often  atro- 
phic rhinitis)  and  have  a  nasal  voice.  As  the  tumor 
extends,  obstruction  of  the  Eustachian  tubes  causes 
deafness  and  pain  in  the  ear;  extension  to  the  cranial 
cavity  causes  headache,  somnolence  and  choked  optic 
disk;  extension  to  the  orbit  causes  disturbance  of 
vision,  e.g.  diplopia.  Pressure  on  the  facial  nerve 
and  trigeminal  causes  paralysis  and  severe  neuralo-ia. 

The  diagnosis  of  these  advanced  sarcomas  pre- 
sents no  difficulty.  The  soft,  fungoid  consistence  of 
the  whole  tumor,  the  tendency  to  bleeding  and  the 
rapid  growth  are  characteristic.  In  extensive  sar- 
comas with  commencing  disintegration  and  dis- 
charge soft  glandular  metastases  are  found.  The 
commencing  sarcomas  can  be  recognized  by  digital 
and  rhinoscopic  examination  as  irregular,  rough, 
infiltrating  tumors,  which  differ  from  the  nodular 
encapsuled  fibromas. 

Differential  Diagnosis.  It  is  only  in  young 
individuals  that  other  lesions  can  be  confounded  with 
true   tumors   of   the    naso-pharynx.     Hypertrophied 

43 


tonsils  and  extensive  adenoids  cause  similar  symp- 
toms, but  digital  examination  and  rhinoscopy  will 
make  the  diagnosis  clear.  In  very  young  children 
teratomas  are  seen  (Fig.  146),  which  may  be  mis- 
taken for  sarcoma  arising  from  the  basilar  process 
and  extending  to  the  face.  However,  teratomas  are 
usually  more  or  less  encapsuled  and  only  appear 
on  one  half  of  the  face. 

Retro-maxillary  tumors  manifest  themselves  at 
first  by  unilateral  pain  in  the  face,  swelling  of  the 
cheek  and  fixation  of  the  corresponding  maxillary 
joint,  but  on  further  extension  they  cannot  be  distin- 
guished from  advanced  tumors  of  the  naso-pharynx, 
or  from  large  tumors  of  the  upper  maxilla  or  orbit. 

Treatment.  The  removal  of  adenoid  vegeta- 
tions is  best  efi^ected  by  Gottstein's  curette.  Even 
extensive  adenoid  growths  may  disappear  sponta- 
neously at  the  age  of  puberty.  Hypertrophied  ton- 
sils are  to  be  removed  by  the  tpnsillotome.  For 
small  fibromas  an  oral  method  may  be  employed,  by 
means  of  division  of  the  soft  palate  and  part  of  the 
hard  palate  {Nclaton,  Gussenhauer)  or  by  temporary 
division  of  the  lower  maxilla.  The  tumors  should 
always  be  removed  by  incision  into  healthy  tissues 
with  the  knife.  In  extensive  fibromas  and  all  tu- 
mors suspected  of  sarcoma,  the  naso-pharynx  must 
be  freely  laid  open,  by  temporary  resection  of  the 
hard  palate  together  with  the  alveolar  process 
(Partsch),  or  by  temporary  resection  of  both  upper 
maxillse  and  raising  up  the  nose  (v.  Bergviann). 
Previous  tracheotomy  and  ligation  of  the  external 
carotid  on  one  or  both  sides  (Kocher,  Konig),  is  ex- 
pedient in  these  sanguinary  operations.  That  very 
large  tumors  can  be  removed  by  extensive  operations 
with  good  results  is  shown  by  the  experience  of 
V.  Bergmann's  clinic.  Even  tumors  which  had  ex- 
tended through  the  base  of  the  skull  and  caused 
symptoms    of    cerebral    pressure    were    successfully 

44 


removed.  Naturally,  the  earlier  diagnosis  is  made 
by  digital  examination  and  rhinoscopy  (excision  for 
examination  is  dangerous  on  account  of  severe 
hemorrhage,  and  also  useless)  the  more  can  these 
complicated  operations  be  avoided,  and  the  more 
frequent  are  radical  cures.  Inoperable  tumors  (Fig. 
'27)  may  be  treated  by  the  X-rays  or  by  the  adminis- 
tration of  arsenic  and  morphia.  When  the  tumors 
fungate  externally  the  ulcerated  parts  must  be  cau- 
terized and  treated  with  moist  disinfectant  dressings. 
In  the  last  stages  tracheotomy  must  be  performed,  to 
save  the  patient  from  death  by  asphj^xia. 

Fig.  25  shows  a  malignant  naso-pharyngeal  poly- 
pus which  arose  from  the  basilar  process  and  was 
at  first  covered  by  the  mucous  membrane  of  the 
epipharynx.  The  disease  was  of  ten  years'  duration. 
Various  polypi  were  removed,  and  also  a  larger 
tumor,  after  partial  resection  of  the  upper  maxilla, 
without  success.  The  sarcoma  then  grew  almost 
exclusively  forwards  through  the  posterior  nares  and 
destroyed  the  whole  bony  framework  of  the  nose. 
The  fairly  symmetrical  growth  on  both  sides  of  the 
middle  line  shows  the  origin  from  the  basilar  process, 
in  distinction  to  the  more  lateral  swelling  of  retro- 
maxillary  tumors.  It  forms  a  soft,  partly  fluctuating 
growth  with  fungatino;  borders  which  has  begun  to 
extend  over  both  eyes.  In  some  places  the  skin  is 
so  thin  that  it  appears  livid  and  transparent ;  in  other 
parts  it  shows  the  great  vascularity  of  the  skin  char- 
acteristic of  sarcoma.  The  tumor,  already  disinte- 
grating, is  on  the  point  of  breaking  through.  The 
whole  nasal  cavity  and  the  whole  naso-pharynx  on 
digital  examination  were  found  to  be  filled  with  soft, 
infiltrating  tumor  masses,  which  had  displaced  the 
soft  palate  downwards  and  forwards,  so  that  the 
growth  could  onlv  have  been  removed  by  very 
extensive  interference.  The  tumor  had  also  extended 
through  the  base  of  the  skull. 

45 


ANGIO -SARCOMA  CUTIS  (of  Skin) 

Plate  XIX,  Fig.  26. 
SARCOMA  FUNGOIDES  ORBITAE  {Fungating  Sarcoma  of  Orbit) 

Plate  XIX,  Fig.  27. 

Fig.  26.  Round-celled  and  spindle-celled  sarco- 
mas of  the  face  are  rare;  angio-sarcoma  is  more 
common.  In  this  case  the  tumor  is  pedunculated 
and  is  characterized  by  its  concentric,  spherical  for- 
mation. The  base  of  the  tumor  is  surrounded  by  a 
ring  of  epidermic  scales.  The  surface  of  the  tumor 
is  of  a  red  color  and  resembles  exuberant  granula- 
tions. It  is  slightly  uneven  and  somewhat  resembles 
a  strawberry.  The  tumor  is  of  very  soft  consistence, 
easily  bleeding  at  the  slightest  touch.  The  malig- 
nancy is  shown  by  its  rapid  growth.  It  is  distin- 
guished from  carcinoma  by  the  absence  of  glandular 
enlargement. 

Differential  Diagnosis.  The  tumor  resembles 
in  appearance  two  diseases — framboesia  tropica  (or 
yaws)  and  botriomycosis.  The  initial  lesion  in  yaws 
is,  however,  soon  followed  by  a  general  eruption 
of  similar  frambcesiform  growths.  The  granular 
growths  in  both  yaws  and  botriomycosis  remain 
superficial,  while  the  sarcoma  extends  into  the 
deeper  tissues. 

In  mycosis  fungoides  multiple  growths  occur  which 
may  develop  into  tumors  resembling  sarcoma. 

Treatment.  Early  and  free  excision.  In  the 
face  the  defect  may  be  repaired  by  a  plastic  operation. 

Fig.  27.  A  very  extensive  sarcoma  involving  the 
left  half  of  the  face  and  already  extending  to  the  right 

46 


Bockenheinier,  Atlas. 


Tab.  XIX. 


-.n 


■r, 


bi 


'-.t 


zr, 


t>j 


Rebman  Company,  Ncvi-York. 


half.  Protruding  from  the  orbit  as  a  fungoid  mass 
the  tumor  is  characteristic  of  sarcoma  (sarcoma 
fungoides).  The  soft  edges  have  the  typical  reddish- 
brown  color  of  sarcoma.  In  the  places  where  the  skin 
is  destroyed  soft  masses  with  a  fairly  regular  surface 
protrude,  which  differ  from  the  ragged  irregular  ulcer 
of  carcinoma.  The  whole  of  the  tumor  situated  in 
the  orbit  is  of  soft,  almost  fluctuating  consistence. 
In  some  parts  the  fungoid  masses  are  breaking  down 
and  covered  with  sanious  dischai-ge.  Blood  crusts 
form  on  the  ulcerations  owing  to  the  fi'equent  hem- 
orrhages in  the  tumor.  The  brown-colored  skin  is 
almost  atrophied  from  pressure  of  the  tumor.  Sar- 
comatous masses  protrude  from  both  nostrils,  and 
the  whole  buccal  cavity  and  naso-pharynx  is  full  of 
tumor  masses,  which  have  caused  complete  destruc- 
tion of  the  bones  of  the  face.  The  tumor  has  also 
extended  through  the  base  of  the  skull,  causing:  ex- 
treme  somnolence.  It  is  no  longer  possible  to  decide 
whether  it  is  a  case  of  malignant  naso-pharyngeal 
pol}^us,  a  retro-maxillary  tumor,  a  maxillary  tumor, 
or  a  periosteal  sarcoma  of  the  orbit.  The  last  is  the 
most  probable,  as  the  tumor  was  first  observed  in  the 
orbit. 

Treatment.    Cf.  Plate  XVII. 


47 


MELANO -SARCOMA  CUTIS  {of  Shin) 
LYMPHOMATA  SARCOMATOSA  COLLI 

{Sarcomatous  Lymphoma  of  Neck) 
Plate  XX,  Fig.  28. 

This  figure  shows  a  hard,  rough,  movable,  brown- 
ish-black tumor  of  the  scalp,  which  rapidly  developed 
from  a  pigmentary  nsevus  in  a  man  of  nineteen. 
(Cf.  Plate  XVI,  Fig.  23.)  The  hardness  and  rapid 
growth  reveal  a  malignant  tumor  the  nature  of  which 
(melano-carcinoma  or  melano-sarcoma)  can  only  be 
decided  by  microscopic  examination,  for  carcinoma 
and  sarcoma  of  the  scalp  are  very  similar.  The 
tumor  has  remained  small  and  is  covered  by  unbro- 
ken, pigmented  skin. 

The  malignancy  of  the  tumor  is  strikingly  shown 
by  the  enormous  enlargement  of  the  regional  lym- 
phatic glands.  Not  only  the  glands  of  the  nape  of 
the  neck,  but  also  all  the  glands  on  the  right  side  of 
the  neck  to  the  supra-clavicular  fossa  are  trans- 
formed into  soft  nodular  tumors.  The  consistence 
of  these  glandular  tumors  is  so  soft  as  to  give  the  sen- 
sation of  fluctuation  (pseudo-fluctuation),  which  is 
characteristic  of  rapidly  growing  sarcomatous  met- 
astases. The  patient  rapidly  succumbed  after  the 
appearance  of  metastases  in  the  lungs  (pleuritis 
exudativa). 

The  glandular  metastases  and  innumerable  nodules 
in  the  lungs  and  heart  were  white  in  color,  the  pig- 
mentation of  the  mother  tumor  often  being  absent 
in  the  rapidly  developing  metastases  of  melanotic 
tumors. 


48 


Bockenheimer,  Atlas. 


Fie.  28.    Melanosarcoma  cutis  -   I.viimliomata  sarconiatosa  colli. 


Rebman  Company,  New-York 


Bockenheimer,  Atlas. 


Tab.  XXI. 


h'ig.  20.     Sarcoma  mammae  e.xulceratum. 


Rcbmaii  Company,  New- York. 


SARCOMA  MAMMAE  EXULCERATUM 

{Ulcerating  Sarcoma  of  Breast) 
Plate  XXI.  Fig.  29. 

SARCOMA  MAMMAE   CYSTICUM  {Cystic  Sarcoma  of  Breast) 
Plate  XXII,  Fig.  30. 

Sarcoma  is  much  less  common  in  the  mammary 
gland  than  carcinoma  (one  hundred  carcinomas  to 
ten  sarcomas,  and  half  of  these  cysto-sarcomas,  v. 
Angerer).  All  cell  forms  of  sarcoma  may  be  repre- 
sented as  well  as  mixed  forms,  such  as  myxo-,  angio-, 
and  melano-sarcoma. 

■  They  occur  most  often  in  young  women.  Accord- 
ing to  their  composition  they  have  different  clinical 
signs.  Spindle-celled  sarcomas  are  of  firm  consist- 
ence and  of  slower  gro^i;h  than  the  soft,  malig- 
nant, round-celled  sarcomas  and  melanosarcomas. 
Cysto-sarcomas  soon  lead  to  extensive  tumors  which 
transform  the  breast  into  a  large  sac  with  fluid 
contents.  The  typical  characteristics  of  sarcoma  are 
generally  present  in  the  mammary  tumors  (Fig.  29). 

Differential  Diagnosis.  Carcinoma  is  distin- 
guished by  the  absence  of  any  demarcation  from  the 
mammary  tissue,  while  sarcoma  is  often  encapsuled. 
Moreover,  the  clinical  signs  of  carcinoma  are  so  char- 
acteristic (cf.  Plates  V-XI)  that  confusion  is  hardly 
possible.  Cysts  of  the  mamma  are  usually  situated 
behind  the  mammilla,  multiple  (in  one  or  both 
mammte),  and  not  so  large  as  true  cysto-sarcoma. 
Fibroadenoma  (to  which  the  tumors  incorrectly 
designated  by  J.  Miiller  as  cystosarcoma  pajjilli- 
ferum  phyllodes,  rightly  belong),  which  originate 
from  the  glandular  tissue  and  show  an   abundant 

49 


development  of  connective-tissue  cells,  are  slow  grow- 
ing, movable  tumors,  and  are  always  encapsuled  (cf . 
Plate  XXVIII). 

Treatment.  Extirpation  of  the  whole  mamma 
as  early  as  possible,  with  free  exposure  of  the  axilla. 
After  early  and  extensive  operations  local  recurrence 
is  rare,  and  permanent  cures  more  frequent  than  in 
carcinoma. 

Fig.  29  shows  a  rapidly  growing,  round-celled  sar- 
coma in  a  young  girl.  The  tumor  forms  a  soft, 
fairly  circumscribed  nodule  in  the  mammary  gland. 
That  the  part  of  the  tumor  lying  in  the  mamma  is 
considerably  larger  than  the  external  appearance  in- 
dicates is  shown  by  the  prominent  veins.  The  tumor 
is  near  the  mammilla  but  has  caused  no  retraction  of 
the  nipple.  It  is  freely  movable  over  the  pectoralis 
fascia.  Externally  it  has  involved  the  skin,  which 
has  the  usual  brownish-red  color  of  sarcoma,  has  be- 
come very  thin  and  is  already  ulcerated  in  one  spot, 
from  which  repeated  hemorrhage  has  taken  place. 
The  fungoid  tumors,  in  distinction  to  carcinoma, 
have  a  smooth,  uniform  surface  and  resemble  exuber- 
ant granulation  tissue.  There  were  no  glands  to  be 
felt  in  the  axilla.  Treated  by  extirpation  of  the 
mamma  and  free  exposure  of  the  axilla. 

Plate  XXII,  Fig.  30. 

A  cystic  tumor  occurring  in  a  young  woman, 
which  has  begun  to  displace  the  whole  breast.  There 
is  no  alteration  in  the  nipple.  The  tumor  is  movable 
over  the  pectoral  fascia,  and  in  several  places  dis- 
tinctly separate  from  the  mammary  tissue.  The  veins 
are  enlarged  from  pressure  of  the  tumor.  The  tumor 
has  already  invaded  the  skin,  which  has  become 
very  thin,  and  in  some  places  fluctuating.  The  skin 
is  colored  brownish  red  and  bluish  green,  and  shows 
a    network    of    vessels.     As    long    as    the    skin    is 

50 


Bockenheiiner,  Atlas. 


Tab.  X.XII 


t'ig.  30.    Sarcoma  mammae  cysticiim. 


tn-in  Coninanv.  NpT-Vorlc. 


intact  it  can  never  be  definitely  ascertained  whether 
it  is  a  case  of  actual  cavities  filled  with  fluid,  or  the 
pseudofluctuation  of  gelatinous  or  mucoid  sarcoma. 
Rapid  growth  and  commencing  soft  glandular  swell- 
ings in  the  axilla  point  to  the  diagnosis  of  a  cysto- 
sarcoma. 

Treatment.     Extirpation    of    the    mamma    and 
removal  of  the  axillary  glands. 


51 


SARCOMA  CUTIS  MULTIPLEX  (Multiple  Sarcoma  of  Skin) 
Plate  XXm,  Fig.  31. 

Multiple  sarcomas  of  the  skin,  pigmented  or  color- 
less, may  be  congenital  and  then  usually  cause  death 
after  spreading  over  the  whole  body.  Melanotic  sar- 
comas arising  from  naevi  and  warts  and  the  forms 
appearing  in  the  skin  as  multiple  nodules  occur  in 
middle  life.  In  old  people  the  multiple  pigmentary 
sarcoma  first  described  by  Kaposi  is  found  (hemor- 
rhagic sarcoma  of  Kbhner).  Multiple  sarcomas  of 
the  skin  always  appear  in  a  characteristic  form,  as 
red  spots  which  soon  become  nodules.  The  nodules 
increase  in  size  and  become  confluent,  thus  forming 
a  tumor  which  is  at  first  movable  over  the  underly- 
ing tissues.  Later  on  the  skin  desquamates  and 
becomes  red,  bluish  or  livid,  then  browner  after  re- 
peated hemorrhages,  and  may  finally  ulcerate.  The 
skin  over  pigmentary  sarcomas  is  bluish  black. 

Besides  the  ulceration  of  the  nodules,  spontaneous 
resolution  is  possible,  complete  or  partial,  leaving  a 
cicatrix.  The  nodular  tumors  may  in  some  cases 
remain  the  same  size  for  years.  The  tumors  are 
always  circumscribed,  and  are  of  soft  or  firm  con- 
sistence according  to  their  composition.  Soft  nodules 
tend  to  disintegration,  hard  nodules  to  atrophy  and 
cicatrization.  The  former  are  very  malignant  and 
soon  lead  to  death  from  glandular  and  organic  metas- 
tases; the  latter,  by  their  multiplicity,  after  some 
years  cause  cachexia,  which  with  metastases  leads  to 
a  fatal  issue.  The  skin  of  the  whole  body  between 
the  nodules  is  often  of  a  dirty  sallow  color  (Fig.  31). 
Small  spots  and  elevations  on  the  skin  point  to  the 
development  of  fresh  sarcomatous  nodules. 

53 


Bockenheimer,  Atlas. 


/ 


Fitr.  31.    Sarcoma  cutis  multiplex. 


Sarcoma  multiplex  hemorrhagicum  pigmentosum 
appears  in  the  form  described  above,  but  first  of  all 
on  the  lower  extremities,  in  the  form  of  reddish 
nodules  which  often  cause  much  itching.  Tumor 
formation  goes  hand  in  hand  with  oedematous  infiltra- 
tion which  extends  over  the  whole  leg  and  prevents 
the  patient  from  walking.  Desquamation  of  the  skin 
on  the  surface  of  the  nodules  occurs  along  with  corni- 
fication  of  the  epidermis.  Cicatrices  form  in  the 
skin  from  atrophy  of  the  nodules.  Other  regions  of 
the  body  are  unaffected,  except  the  peripheral  parts 
of  the  upper  extremity.  There  is  no  enlargement  of 
the  lymphatic  glands.  The  disease  runs  a  progres- 
sive course,  and  in  spite  of  the  spontaneous  resolution 
of  some  of  the  tumors,  finally  causes  death  by 
marasmus. 

Microscopic  examination  shows  a  pure  sarcoma 
with  abundant  blood-vessels,  which  often  gives  rise  to 
organic  metastases.  As  this  form  occurs  exclusively 
in  old  people,  arteriosclerosis  may,  perhaps,  account 
for  the  origin  and  course  of  the  disease.  {Kobner, 
Schlesinger) . 

Differential  Diagnosis.  Primary  multiple  sar- 
comas must  not  be  confounded  with  secondary 
sarcomatous  growths  in  connection  with  a  primary 
cutaneous  sarcoma  or  a  sarcoma  of  the  internal 
organs.  The  tumors  of  mycosis  fungoides  are  more 
likely  to  be  mistaken  for  sarcoma,  as  they  also  de- 
velop from  red,  uneven  spots,  and  form  granulation 
tumors  of  a  brownish-red  color  which  in  the  later 
stages  tend  to  ulceration  and  cachexia;  but  mycosis 
fungoides  is  of  much  slower  growth  than  sarcoma. 
Syphilitic  and  tuberculous  granulomas  can  hardly  be 
confounded  with  sarcoma  on  careful  examination. 

Treatment.  Preventive  treatment  of  multiple 
sarcoma  consists  in  the  removal  of  all  msvi  which 
begin  to  take  on  rapid  growth.     In  already  existing 

53 


multiple  pigmentary  sarcomas  excision  is  generally 
useless,  and  should  only  be  performed  when  the 
tumors  are  few  in  number  and  the  blood-vessels  free 
from  melanin.  After  excision  of  multiple  sarcomas, 
especially  melanosarcomas,  death  often  follows  from 
rapid  dissemination  and  organic  metastases.  Hence 
the  X-rays,  large  doses  of  arsenic  (internally  or 
subcutaneously)  have  been  employed  for  multiple 
cutaneous  sarcomas,  in  the  same  way  as  for  mycosis 
fungoides.  A  permanent  cure,  however,  is  not  to  be 
expected  as  the  prognosis  of  these  multiple  sarcomas 
is  always  bad. 

Fig.  31  shows  a  case  of  multiple  sarcoma  of  the 
skin  affecting  the  whole  of  the  thorax,  abdomen  and 
back.  Some  of  the  nodules  have  already  atrophied 
leaving  cicatrices.  The  new  growth  of  nodules,  how- 
ever, exceeds  the  atrophy  so  that  the  patient  became 
more  and  more  cachectic  in  spite  of  treatment. 


54 


Bockenlieimer,  Alias. 


Tab.  XX  1\'. 


Fig.  32.     Sarcoma  huineri  periphericum. 


Rcbman  Company,  New-York. 


SARCOMA  HUMERI  PERIPHERICUM 

(Peripheral  Sarcoma  of  Humerus) 
Plate  XXrV\  Fig.  32. 

Sarcomas  arising  from  the  bones  are  of  special 
interest  on  account  of  their  frequency. 

Osteo-sarcomas  are  best  divided  into  peripheral 
and  central;  the  latter  may  arise  from  the  cortical, 
spongy  or  medullary  portions.  Division  into  perios- 
teal and  myelogenous  tumors  is  clinically  impossi- 
ble, and  the  word  myelogenous  may  be  replaced  by 
osteal.  Tumors  which  appear  clinically  to  be  peri- 
osteal often  arise  from  the  superficial  layers  of  the 
cortex.  By  the  use  of  the  X-rays  it  is  more  easy  to 
divide  them  into  peripheral  and  central  tumors;  this 
leaves  open  the  possible  origin  of  the  sarcoma  from 
any  part  of  the  bone,  and  this  can  only  be  conclu- 
sively settled  by  section  of  the  bone  after  removal. 
This  classification  is  all  the  more  rational  because 
sections  of  preparations  which  were  clinically  re- 
garded as  periosteal  sarcomas  show  that  these  arose 
from  small  foci  in  the  medullary  cavity.  Periosteal 
tumors  may  extend  into  the  medullary  cavity  and  so 
simulate  osteal  tumors.  In  extensive  tumors  the 
origin  of  the  tumor  from  any  definite  part  of  the 
bone  cannot  as  a  rule  be  established. 

Both  forms  have  special  seats  of  predilection: 
in  the  long  bones,  the  neighborhood  of  the  epiphyses 
e.g.  the  upper  end  of  the  humerus  (Fig.  3-2),  the  lower 
end  of  the  femur,  especially  the  internal  condyle,  the 
head  of  the  tibia,  the  lower  end  of  the  radius;  the 
flat  bones,  especially  the  scapula  and  bones  of  the 
skull.  Both  forms  also  grow  in  a  globular  form 
involving  the  whole  circumference  of  the  bone  and 

55 


finally  its  whole  thickness.  They  appear  at  puberty 
and  during  the  whole  period  of  growth,  generally  in 
young  and  robust  individuals. 

Both  forms  are  distinguished  by  the  fact  that  they 
soon  break  through  their  own  capsule  and  that  of 
the  bones  and  then  extend  into  the  neighboring  joints 
and  muscles,  especially  the  muscular  insertions  into 
the  bones,  and  into  the  veins,  forming  eventually 
enormous  tumors  which  break  through  the  skin  and 
appear  as  fungoid  masses.  The  superficially  situ- 
ated tumors  have  a  tendency  to  frequent  hemorrhage 
and  destructive  inflammation.  Primary  sarcomas  of 
bone  are  very  rare  and  are  sometimes  confounded 
with  sarcoma-like  changes  in  the  bones  which  result 
from  ostitis  fibrosa;  also  with  formations  which  do 
not  belong  to  tumors  in  the  strict  sense,  but  are 
known  as  myelomas  (especially  in  the  blood-forming 
vertebral  bodies). 

Microscopically,  spindle  cells  are  often  found  in 
peripheral  sarcoma,  and  giant  cells  in  central  sar- 
coma. The  other  forms  of  sarcoma  cells  are  also 
present. 

The  X-rays,  in  peripheral  sarcoma,  show  little 
change  in  the  cortex.  In  central  tumors,  especially 
those  arising  from  the  meduUaiy  cavity,  they  often 
show  spherical  transparent  spaces  in  the  interior, 
while  the  cortex  is  very  thin  and  excavated — forming 
a  shell — in  the  same  way  as  in  bony  cysts,  osteo- 
myelitic  abscesses,  isolated  tuberculosis  and  gumma. 

In  the  early  stages  the  diagnosis  of  osteo-sarcoma 
is  difficult.  The  peripheral  tumors  are  naturally 
more  easy  to  diagnose,  as  they  present  a  rapidly 
growing  tumor  firmly  attached  to  the  bone,  with 
irregular  boundaries  towards  the  muscles.  Rheu- 
matic pains  and  effusion  into  the  joints  frequently 
occur  when  the  tumors  are  situated  near  the  joints. 
The  nearer  the  sarcoma  approaches  the  skin  the 
easier  it  is  to  recognize  the  superficial  tumor  masses, 
which  infiltrate  the  soft  tissues,  and  consist  of  cells 

56 


only  without  bony  infiltration.  Swelling  of  the  cuta- 
neous veins  occurs  early  from  pressure  of  the  tumor 
on  the  vessels  (Fig.  32),  while  the  skin  becomes  red- 
dish brown,  thin  and  almost  transparent,  especially 
when  the  tumor  is  attached  to  it. 

Slow-growing  central  sarcomas  can  only  at  first 
be  diagnosed  by  the  X-rays,  later  on  they  present 
themselves  as  hard  spheroidal  swellings  like  billiard 
balls.  The  more  they  extend  and  approach  the 
skin,  the  thinner  becomes  their  bony  shell,  which 
finally  gives  the  sensation  of  parchment  crepitation, 
first  described  by  Dupuytren.  Central  tumors  are 
often  first  diagnosed  by  the  occurrence  of  sponta- 
neous fracture.  Extensive  forms,  which  assume  a 
more  spindle-celled  formation  are  easy  to  recognize. 
Through  growth  of  the  tumor  into  the  joints  and 
muscles,  typical  functional  derangements  are  pro- 
duced, and  separation  of  the  epiphyses.  Metastases 
in  the  lungs  develop  early.  Disintegration  of  the 
tumor  cells  gives  rise  to  fever,  especially  in  rapidly 
growing,  small,  round-celled  sarcomas. 

Differential  Diagnosis.  Parosteal  sarcomas  are 
easily  mistaken  for  peripheral  sarcoma,  and  are  often 
impossible  to  distinguish  by  the  X-rays.  They  are 
often  of  very  soft  consistence,  and  were  formerly 
called  encephaloid. 

Chondrosarcoma  only  occurs  in  the  neighborhood 
of  the  joints  and  forms  irregular  nodular  tumors 
(Fig.  34). 

Sarcomas  situated  near  the  large  vessels  and  pul- 
sating with  them,  may  be  mistaken  for  aneurism, 
but  the  X-rays  will  assist  the  diagnosis.  Central  sar- 
comas have  been  wrongly  considered  as  aneurism  of 
the  bone,  owing  to  their  vascularity  and  their  red- 
dish-brown color  on  section,  which  is  due  to  frequent 
hemorrhatres. 

Myelomas  are  multiple  and  occur  chiefly  in  the 
vertebrae. 


Metastatic  carcinomas,  which  occur  especially  in 
the  neck  of  the  femur  after  mammary  carcinoma  in 
women,  and  in  the  head  of  the  humerus  after  carci- 
noma of  the  thyroid  gland  {v.  Eiselsberg),  must  be 
diagnosed  by  the  primary  growth. 

Osteo-sarcomas  may  possibly  be  confounded  with 
inflammation  of  joints,  rheumatism,  osteo-myelitis, 
syphilitic  and  tuberculous  processes;  but  in  most 
cases  the  diagnosis  can  be  made  by  the  history  of 
the  case,  by  the  X-rays,  by  anti-syphilitic  treat- 
ment, and  in  osteomyelitis  by  search  for  hemolysin 
(Bruck,  Michaelis,  Schultze).  The  uninterrupted 
diffuse  growth  should  always  raise  the  suspicion  of 
malignant  tumor.  In  doubtful  cases  an  exploratory 
incision  may  be  made. 

In  all  cases  the  prognosis  is  very  bad.  The  harder 
forms  of  sarcoma  (spindle-celled  and  giant-celled) 
sometimes  have  a  better  prognosis.  The  soft,  round- 
celled  sarcomas  are  the  most  malignant  on  account 
of  their  rapid  growth  and  early  metastasis. 

Treatment.  The  earlier  operative  treatment  is 
undertaken,  the  more  likely  is  a  radical  cure. 

Small,  central  sarcomas  can  be  removed  by  the 
chisel,  and  the  medullary  cavity  scraped.  Larger 
circumscribed  tumors  still  confined  to  the  bone  can 
be  removed  by  free  resection  of  bone.  The  defect 
can  be  repaired  by  bone  grafting  (auto-  or  hetero- 
plastic). 

If  the  sarcoma  has  already  invaded  the  muscles 
amputation  must  be  performed.  When  the  tumor  is 
near  the  joint  of  one  of  the  bones  of  the  extremities, 
disarticulation  is  necessary;  when  in  a  flat  bone 
total  extirpation. 

Inoperable  sarcomas  are  to  be  treated  according 
to  the  rules  for  inoperable  tumors  (cf.  Plate  XVII). 

Fig.  32  shows  a  peripheral  sarcoma  of  the  upper 
end   of  the    humerus   in  a  young  individual.     The 

58 


soft  tumor  has  extended  under  the  skin,  in  which 
the  brown  coloring  and  extensive  network  of  dilated 
veins  are  very  marked.  The  lower  borders  of  the 
fusiform  tumor  are  irregular  and  send  processes  here 
and  there  into  the  muscles.  The  tumor  has  destroyed 
the  head  of  the  humerus  and  has  broken  through 
into  the  joint,  in  which  there  is  effusion.  The  func- 
tion of  the  joint  and  upper  arm  is  destroyed.  The 
supra-clavicular  glands  are  enlarged.  Posteriorly 
the  tumor  has  extended  to  the  scapula  region.  The 
X-rays  showed  complete  destruction  of  the  upper 
part  of  the  humerus.  As  there  was  no  evidence  of 
organic  metastases,  the  arm  and  shoulder  girdle 
(scapula  and  outer  half  of  the  clavicle)  were  re- 
moved after  section  through  the  middle  third  of  the 
clavicle  and  ligation  of  the  subclavian  artery  and 
vein.  The  axillary  and  supra-clavicular  glands  were 
also  removed. 

On  section,  the  whole  of  the  upper  portion  of  the 
humerus  was  found  to  be  transformed  into  a  large 
tumor,  the  central  parts  of  which  were  hard  from 
bony  infiltration,  while  the  periphery  was  soft  and 
fungoid.  The  tumor  was  a  round-celled  sarcoma, 
but  it  was  too  extensive  to  decide  from  which  part 
of  the  bone  it  originated. 


59 


SARCOMA  FASCIAE  EXULCERATUM 

(Ulcerating  Sarcoma  of  Brachial  Fascia) 
Plate  XXV,  Fig.  33. 

Fascia  and  the  sheaths  of  blood-vessels  are  often 
the  starting  point  of  sarcomas;  not  only  of  pure 
round-celled  and  spindle-celled  sarcomas,  but  more 
often  of  mixed  forms — myxosarcoma  and  fibro- 
sarcoma. Fibrosarcomas  are  characterized  by  their 
firm  consistence  and  slow  growth;  they  are  fre- 
quently circumscribed  and  partly  encapsuled.  Myxo- 
sarcomas are  characterized  by  their  softness  and 
rapid  growth  without  encapsulation.  The  pure  sar- 
comas appear  as  soft,  many-celled,  rapidly  growing 
tumors,  or  in  a  harder  form  which  is  of  slower 
growth  and  not  so  malignant. 

In  the  early  stages  of  fascial  sarcomas  (fascia  of 
the  arm,  fascia  lata,  abdominal  fascia)  we  find  small 
tumors  fixed  to  the  fascia,  but  movable  over  subja- 
cent tissues  and  under  the  skin.  The  skin  is  soon 
involved  and  becomes  tightly  stretched  over  the 
tumor  and  pigmented,  and  finally  the  tumor  breaks 
through  it.  At  the  same  time  the  muscles  and 
eventually  the  whole  section  of  the  body  are  infiltra- 
ted with  tumor  substance  (bones,  joints,  peritoneal 
cavity).  The  chief  growth,  however,  takes  place  on 
the  external  surface  in  the  form  of  nodular  fungoid 
tumors  which  exhibit  all  the  characteristics  of  sar- 
coma. They  are  of  soft  consistence,  both  in  the 
center  and  at  the  periphery;  the  surface  is  much 
smoother  than  in  carcinoma,  bleeds  easily  on  account 
of  its  numerous  blood-vessels,  and  is  covered  with 
sanious  discharge.  Nodules  succeed  one  another  till 
an  enormous  cauliflower  growth  is  formed  (Fig.  33). 

60 


Bockenheimer,  Atlas. 


Tab.  XXV. 


'X) 


CO 


U 


Rebman  Com.iany,  New- York. 


Ulceration  of  the  tumor  is  followed  by  regional 
glandular  metastases,  organic  metastases,  fever  and 
severe  anaemia. 

Differential  Diagnosis.  These  rapidly  growing 
malignant  tumors  are  so  typical  in  their  situation  and 
development  that  it  is  only  on  the  scalp  that  they  can 
be  mistaken  for  ulcerating  carcinoma.  Sarcomas  of 
the  scalp  often  have  hard  borders  with  deep  fissures 
as  in  carcinoma,  and  also  give  rise  to  early  glandular 
enlargement. 

Treatment.  Small,  slow-growing  sarcomas  can 
be  removed  by  free  excision,  but  local  recurrence  is 
frequent.  In  extensive,  and  especially  in  ulcerated, 
tumors  of  the  extremities  amputation  is  indicated. 
Tumors  which  arise  in  the  abdominal  fascia  often 
become  inoperable  owing  to  extension  to  the  peri- 
toneal cavity. 

Fig.  33  shows  a  rapidly  growing,  recurrent,  ulcer- 
ated sarcoma  of  the  fascia  of  the  arm.  The  younger 
nodules  are  covered  by  livid  skin,  which  is  intact  in 
some  parts  and  thin  in  others.  In  other  parts  there 
are  white  cicatrices  left  by  former  operations.  The 
X-rays  showed  that  the  sarcoma  had  extended  to  the 
bone.  Owing  to  the  growth  having  broken  into  the 
elbow  joint,  this  was  fixed  in  the  rectangular  position. 
There  were  some  small,  soft,  enlarged  glands  in  the 
axilla.  Amputation  through  the  arm  was  performed, 
with  removal  of  the  axillary  glands. 


61 


CHONDROMYXOSARCOMA— EXOSTOSES  MALIGNAE 

{Malignant) 
Plate  XX^^,  Fig.  34. 

Chondrosarcomas  are  situated  on  or  near  the 
joints.  Most  frequently  they  arise  from  the  head  of 
the  tibia  or  the  upper  end  of  the  humerus,  also  from 
the  lower  end  of  the  radius.  They  may  also  origi- 
nate from  previous  chondromas  of  the  phalanges, 
metacarpal  and  metatarsal  bones.  They  generally 
form  large,  nodular,  hard  tumors  consisting  of  hya- 
line cartilage,  osseous,  mucoid  and  sarcomatous  tis- 
sue and  contain  cystic  cavities  due  to  softening  and 
hemorrhage.  They  then  resemble  in  appearance 
benign,  cystic  chondrofibromas. 

They  often  form  rapidly  growing  tumors  which 
destroy  the  bones  and  joints  and  give  rise  to  sarcoma- 
tous metastases  containing  no  cartilage.  Their  prog- 
nosis is,  therefore,  very  bad.  In  young  individuals 
they  cause  disturbance  in  growth  (shortening,  etc.). 
Spontaneous  fractures  are  frequent  in  the  forms 
which  show  an  abundant  development  of  sarcomatous 
tissue  and  much  cystic  degeneration.  In  chondro- 
mas arising  from  cartilaginous  exostoses,  which,  like 
the  chondromas  of  Virchoiv,  are  due  to  arrested  de- 
velopment of  the  skeleton  and  disturbances  in  growth, 
chondrosarcomas  may  also  develop.  The  tumors  are 
so  typical  that  they  cannot  be  mistaken  for  otlier 
growths. 

Fig.  34  shows  a  nodular  tumor  of  almost  bony 
hardness  arising  from  the  tibia.  Some  portions  of 
the  tumor  are  soft.  The  tumor  has  pushed  forward 
under  the  skin,  which  has  become  thin  and  livid,  and 

62 


Bockenheimer,  Atlas. 


Tab.  XXVI. 


Fig.  34.     Cliondroniy.xusarcoma  —  Exostoses  malignac. 


is  broken  through  in  some  places  through  which  the 
tumor  is  beginning  to  discharge.  The  movements  of 
the  knee  joint  are  very  hmited.  No  glandular  or 
organic  metastases  were  found. 

Treatment.  Removal  of  the  sarcomatous  exos- 
toses, and  resection  of  the  joint,  if  necessary.  In 
large  tumors,  amputation  and  disarticulation.  Pro- 
phylactic treatment  consists  in  the  removal  of  rapidly 
growing  exostoses  and  chondromas. 


63 


SARCOMA  GIGANTO  CELLULARE  (Gtant-celM)— EPULIS 
Plate  XXVII,  Fig.  35. 

The  name  epulis  has  been  given  to  sessile  or  pedun- 
culated fibrosarcomas  with  numerous  spindle  and 
giant  cells,  arising  from  the  periosteum  or  alveolar 
connective  tissue  of  the  upper  and  lower  jaw.  They 
are  hard  or  soft  tumors  according  to  the  nature  of 
the  cells,  with  a  smooth  surface  covered  by  mucous 
membrane,  of  rounded  form  and  the  size  of  a  walnut. 
They  grow  rapidly  in  women  during  pregnancy.  In 
rare  cases  they  are  ulcerated.  In  children  and  young 
people  they  occur  equally  in  both  sexes.  They  often 
arise  in  the  spaces  between  the  teeth,  and  then  have 
the  impressions  of  the  neighboring  teeth  on  their 
surface.  Sometimes  they  develop  from  the  lateral 
surface  of  the  alveolus  and  then  grow  over  the  teeth, 
usually  the  molars,  which  they  may  loosen.  They 
are  very  vascular  and  bleed  easily,  but  cause  no  other 
trouble. 

The  tumors,  although  they  are  sarcomas,  have 
usually  a  good  prognosis,  for  their  growth  remains 
circumscribed,  rarely  involves  the  bone  and  gives 
rise  to  no  glandular  or  organic  metastases.  They 
only  assume  a  malignant  character  by  their  frequent 
recurrence  after  incomplete  operations. 

Differential  Diagnosis.  Polypi  of  the  gums 
arising  from  alveolar  fistula  and  bad  teeth  do  not 
attain  the  size  of  epulis.  The  flaccid  fibromas  of  the 
gum  seen  in  leontiasis  ossea  do  not  form  globular 
tumors,  and  are  only  slightly  vascular. 

Carcinomas    occur   at  a  later   age,   seldom   arise 

64 


Bockenheimer,  Atlas. 


Tab.  XXVII 


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O 


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o 

CO 


LT, 


in 


ti 


Rebraan  Company,  New- York. 


from  the  alveolar  border,  and  can  easily  be  rccotr- 
nized  by  their  hard  borders,  fissures,  and  glandular 
metastases. 

Treatment.  Epulis  should  never  be  removed 
with  scissors.  The  part  of  the  alveolar  border  from 
which  it  arises  should  always  be  removed  with  the 
chisel.  Hemorrhage  can  be  arrested  by  plugging 
with  iodoform  gauze  after  previous  irrigation  with 
hot  saline  solution,  or  by  cauterization.  Recurrence 
is  rare  after  thorough  removal. 

Fig.  35  shows  a  soft  tumor  the  size  of  a  cherry 
arising  from  the  alveolar  border  of  the  first  right 
bicuspid  tooth,  in  a  young  woman,  which  has  grown 
rapidly  during  pregnancy.  On  the  surface  is  a  pin- 
point ulceration  from  which  frequent  hemorrhage 
has  occurred.  It  was  removed  by  chiseling  the 
alveolar  border. 


65 


HEMANGIOMA  CAVERNOSUM  LINGUAE 

{Cavernous  Hemangioma  of  Tongue) 
Plate  XXVII,  Fig.  36. 

Hemangioma  cavernosum  (cavernoma  linguse 
generally  develops  from  a  previous  congenital  hem- 
angioma simplex,  a  slightly  raised  red  spot  which 
often  remains  unnoticed.  It  may  also  occur  as  a 
congenital  tumor  which  becomes  fully  developed  in 
adolescence  or  sometimes  later,  and  extends  more 
deeply  than  simple  hemangioma  into  the  mucous 
membrane  and  sub-mucous  tissue.  The  tumor  con- 
sists of  new  blood-vessels,  especially  capillaries,  and 
cavities  lined  by  endothelium  and  filled  with  blood. 
The  cavernoma  presents  itself  as  a  tumor  with  sev- 
eral small  nodular  projections  on  its  surface,  which 
have  a  bluish,  glistening  appearance.  The  mucous 
membrane  in  the  region  of  the  tumor  is  so  thin  that 
a  dark  fluid  mass  appears  to  be  seen  through  it. 
Apart  from  this  characteristic  appearance,  the  soft- 
ness of  the  tumor,  and  the  fact  that  it  can  be  emptied 
by  pressure  and  made  tense  by  bending  the  head 
are  worthy  of  notice.  It  thus  consists  of  cavernous 
tissue,  such  as  is  found  normally  in  the  corpora 
cavernosa  penis,  and  on  this  account  the  name 
erectile  tumor  has  been  applied  to  it.  Besides  the 
superficial  growth  there  is  also  a  deeper  growth  into 
the  mucous  membrane,  so  that  the  tumor  may  in- 
volve the  whole  tongue,  the  floor  of  the  mouth,  the 
soft  palate,  the  lips  and  the  cheeks.  Eventually  the 
tumor  may  involve  the  whole  side  of  the  face 
and  extend  through  the  orbit  to  the  brain.  In 
other  cases  the  tumors  are  encapsuled.  Sometimes 
there    are    multiple    encapsuled    cavernomas    lying 

66 


close  together,  but  without  any  direct  connection. 
Tumors  which,  arising  from  the  buccal  mucous  mem- 
brane, appear  under  the  skin  of  the  face,  give  rise 
to  thinning  and  a  bluish  glistening  coloration  of  the 
skin.  Apart  from  the  deformity  large  cavcrnomas 
are  dangerous,  as  they  may  rupture  and  give  rise  to 
profuse  and  sometimes  fatal  hemorrhage,  as  often 
occurs  in  cavernomas  of  internal  organs  (alimentary 
canal  and  liver).  Sometimes  ulceration  occurs  at 
the  points  of  rupture,  which  may  cause  general  sep- 
tic infection,  and  in  the  tongue  acute  glossitis  and 
oedema  of  the  glottis. 


fe' 


Differential  Diagnosis.  Cavernous  lymphan- 
giomas are  composed  of  larger  protuberances  and 
have  a  greenish  surface.  Moreover,  lymphangioma, 
though  diminished  by  pressure,  remains  independent 
of  the  circulation  and  is  not  increased  by  pressure, 
stooping  or  coughing.  As  the  result  of  inflammatory 
changes,  hard  nodules  form  in  these  tumors,  which 
are  disseminated  in  the  soft  parts.  Sarcomas  are 
rare  and  can  generally  be  recognized  by  their  smooth 
surface  and  rapid  growth.  Retention  cysts  of  the 
mucous  membrane  of  the  tongue  are  smaller,  circum- 
scribed, and  have  a  uniform  surface.  On  the  other 
hand,  they  are  also  covered  by  thin,  bluish,  glistening 
mucous  membrane. 

Treatment.  Simple  hemangiomas  of  the  mu- 
cous membrane  should  be  removed  by  caustics  or 
cauterization.  Cavernous  hemangiomas  can  be  ex- 
tirpated if  they  are  encapsuled.  Injection  of  per- 
chloride  of  iron  renders  the  boundaries  of  the  tumor 
visible  and  prevents  hemorrhage,  but  is  dangerous  on 
account  of  possible  embolism. 

Diffuse  cavernous  angiomas  are  best  incised  and 
scraped  with  the  sharp  spoon  (i'.  Bergmann).  Large 
vessels  can  be  ligatured  and  the  bleeding  surface  cau- 
terized, treated  with  hot  saline  solution  or  tamponed 


with  iodoform  gauze  or  sterile  sponges.     The  opera- 
tion must  be  repeated  if  recurrence  takes  place. 

Inoperable  tumors  are  best  treated  with  injections 
of  alcohol,  or  with  Payr's  magnesium.  Both  meth- 
ods aim  at  thrombosis,  after  which  shrinking  of  the 
tumor  takes  place.  Injections  must  be  made  deeply 
under  the  mucous  membrane  to  avoid  necrosis. 

Fig.  36  shows  an  encapsuled  hemangioma  arising 
from  a  simple  cavernoma  after  puberty,  with  the 
characteristic  changes  described  above.  The  tumor 
was  treated  by  incision  and  scraping. 


68 


Bockenheiiiier,  Atlas. 


Tab.  XXVI II. 


-a 


M 


1?^\^^'>„     r««,.%......        VBiv^Vorl- 


FIBRO -ADENOMA  MAMMAE  CYSTICUM 

(Cystic  Fibro-adenoma  of  Breast) 
Plate  XXVIII,  Fig.  37. 

Adenomas,  distinguished  as  true  tumors  (from 
hyperplasias)  by  the  irregular  arrangement  of  the 
newly  formed  glands,  are  rare  in  the  breast,  like  pure 
fibromas.  Of  the  benign  tumors  of  the  breast  only 
fibro-adenomas  come  into  consideration,  as  other  tu- 
mors are  very  rare  (myxoma,  angioma,  chondroma, 
and  mixed  tumors). 

Fibro-adenomas  usually  develop  in  the  peripheral 
portions  of  the  mammary  gland  in  young  women,  in 
the  form  of  slow-growing,  nodular  tumors,  which  are 
so  well  encapsuled  that  they  are  freely  movable 
within  the  breast.  They  are  rarely  multiple  and  sel- 
dom affect  both  breasts.  When  there  is  an  abun- 
dant development  of  connective  tissue  the  tumors  are 
firm;  when  cystic  cavities  develop  they  are  soft  and 
fluctuating  (fibroadenoma  cysticum). 

The  tumor  described  as  cystadenoma  papilli- 
ferum, fibroma  intracanaliculare,  and  incorrectly  as 
sarcoma  phyllodes,  which  is  formed  by  connective 
tissue  processes  covered  by  epithelium  projecting  into 
the  cavity  of  the  cyst,  belongs  to  the  group  of  benign 
mammary  tumors.  In  older  women,  especially  at 
the  menopause,  small  multiple  cystadenomas  occur, 
chiefly  in  the  region  of  the  nipple,  without  causing 
retraction;  sometimes  in  both  breasts.  These  feel 
like  solid  tumors  owing  to  their  thickened  walls.  The 
name  of  chronic  cystic  interstitial  mastitis  has  been 
given  to  these  tumors  by  Konig. 

The  benign  nature  of  these  tumors  is  shown  by  the 
fact  that  they  cause  neither  glandular  nor  organic 

69 


metastases.  On  the  other  hand,  these  tumors,  espe- 
cially cystic  fibroadenomas,  after  slow  increase  in 
size  may  become  enormous  growths,  as  large  as  a 
man's  head,  and  then  cause  much  inconvenience  by 
their  weight,  and  also  radiating  pains  in  the  arm. 
Moreover,  there  is  a  possibility  of  a  transformation 
into  carcinoma  or  sarcoma. 

Differential  Diagnosis.  Chronic  interstitial 
mastitis  may  give  rise  to  a  nodular  infiltration  of  the 
mammary  gland,  but  this  disappears  under  treat- 
ment by  cleansing  the  nipple,  injection  of  alcohol 
into  the  nodules,  and  suspension  of  the  breast;  in 
distinction  to  the  steady  growth  of  tumors.  Cysts 
occur  chiefly  in  the  neighborhood  of  the  nipple,  from 
which  a  brownish  fluid  can  be  expressed.  When  they 
appear  under  the  skin  they  can  be  recognized  by 
their  bluish,  glistening  surface.  Metastatic  tumors 
which,  as  in  carcinoma,  especially  occur  in  the  gen- 
erative organs,  are  often  only  to  be  distinguished  by 
the  presence  of  the  primary  tumors  and  cachexia, 
for  they  appear  in  the  form  of  encapsuled  movable 
nodules  like  benign  tumors,  and  are  also  of  slow 
growth.  Thus,  an  encapsuled  tumor  in  the  breast 
proved  to  be  a  metastasis  of  a  chorionepithelioma  of 
the  uterus,  in  one  of  the  author's  cases.  Primary 
carcinomas,  especially  scirrhus  forms  in  old  women, 
are  recognized  by  their  hardness  and  irregular  bor- 
ders (cf.  Plates  V-XI). 

Treatment.  The  tumor  should  be  exposed  by 
an  incision  radiating  from  the  nipple  (but  avoiding 
it)  and  extirpated  with  the  adjacent  mammary  tissue. 
Early  removal  of  all  chronic  nodular  formations  in 
the  breast  is  advisable.  In  doubtful  cases  an  explor- 
atory incision  may  be  made.  Large  tumors  can  be 
removed  subcutaneously  by  raising  the  breast  through 
a  curved  incision  at  its  lower  border  {Kocher).  In 
very  extensive  growths,  especially  cystic  fibroadeno- 

70 


mas  and  multiple  cystic  formations,  the  whole  breast 
should  be  removed. 

Fig.  37  shows  the  right  breast  of  a  woman  (at  the 
menopause)  much  more  projecting  than  the  left. 
The  upper  half  of  the  right  breast  is  involved  in  a 
tumor,  the  irregular  surface  of  which  can  be  recoo-- 
nized  by  the  bulging  of  the  skin.  The  skin  is  thfn 
and  reddened.  The  tumor,  which  was  at  first  re- 
mote from  the  nipple  in  the  inner  and  upper  quad- 
rant of  the  breast,  has  grown  towards  the  nipple 
without  causing  retraction.  The  tumor  is  com- 
pletely encapsuled,  freely  movable,  and  of  moderately 
hard  consistence.  It  was  removed  through  a  radial 
incision,  together  with  the  adjacent  mammary  tissue. 


71 


CORNU   CUTANEUM  (Cutaneous  Horn) 
ADENOMA  SEBACEA  (Sebaceous) 
Plate  XXIX,  Fig.  38. 

Cutaneous  horns  occur  more  frequently  in  old  peo- 
ple (senile  keratoma),  and  in  those  subject  to  expo- 
sure (sailors,  etc.).  They  arise  on  the  basis  of 
sebaceous  and  dermoid  cysts  and  warts,  and  occur 
on  the  eyelids,  nose,  lips,  cheeks  and  ears,  also  on  the 
scalp  and  genital  organs.  They  are  seldom  multiple. 
They  generally  form  sessile,  freely  movable,  curved 
or  spiral  structures  which  have  an  irregular,  grooved, 
yellowish-brown  surface  and  a  horny  consistence. 

These  benign  formations,  which  may  attain  the 
length  of  several  centimeters,  are  formed  by  a  pro- 
liferation of  the  horny  layer  of  the  epidermis.  The 
papillae  are  also  lengthened,  which  accounts  for  the 
soft  consistence  of  the  interior. 

Differential  Diagnosis.  In  young  people  mul- 
tiple nsevi  with  cornification  occur,  but  these  have  a 
wider  base,  and  a  flatter  and  more  prickly  surface, 

Treatment.  As  about  10  per  cent,  of  cutaneous 
horns  develop  into  carcinoma,  excision  by  the  knife 
into  the  healthy  skin  is  indicated.  Recurrence  takes 
place  after  removal  by  ligature. 

Fig.  38  shows  a  slightly  curved  cutaneous  horn 
about  one  and  one-half  centimeters  long,  occurring 
in  an  old  countrywoman,  in  the  zygomatic  region, 
with  all  the  characteristic  features.  The  skin  at  the 
base  of  the  growth  is  scaly  and  somewhat  reddened. 

Adenoma  of  the  skin  is  another  form  of  growth 
often    occurring    in    women,    both    young    and    old. 


Bockenheimer,  Atlas 


Tab.  XXIX. 


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CO 


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Rebman  Company,  New-York. 


usually  on  the  face.  Adenomas  are  benign  tumors 
which  develop  from  normal  glandular  tissue,  and 
may,  therefore,  occur  in  all  glands.  Adenomas  which 
develop  in  places  where  glands  are  normally  absent 
must  be  assumed  to  develop  from  congenital  rudi- 
ments of  supernumerary  glands. 

In  the  skin,  adenomas  often  develop  from  the  se- 
baceous glands  (adenoma  sebaceum).  They  often 
occur  in  many  places  as  small,  round,  flat,  circum- 
scribed, encapsuled,  movable  tumors,  of  firm  con- 
sistence, and  with  a  dirty  gray  surface.  The  lymphatic 
glands  are  never  affected,  and  there  is  no  recurrence 
after  extirpation.  Adenomas  which  have  become 
transformed  into  carcinomas  have  been  incorrectly 
termed  malignant  adenomas. 

Differential  Diagnosis.  Intercurrent  cystic 
formation  may  cause  confusion  with  endothelioma  of 
the  skin,  and  ulceration  with  carcinoma.  The  oc- 
currence of  calcification  in  the  adenoma  may  make 
it  as  hard  as  carcinoma.  Doubtful  cases  must  be 
settled  by  microscopic  examination. 

Treatment.  Small  multiple  adenomas  can  be 
treated  by  cauterization  or  X-rays.  Larger  ones 
should  be  extirpated. 

Adenomas  arising  from  the  sweat  glands  (adenoma 
sudiporum)  generally  form  larger,  more  nodular  tu- 
mors, which  after  ulceration  simulate  carcinomas. 
The  treatment  consists  in  excision. 

Fig.  38  shows  multiple  pin-point  adenomas  of  the 
sebaceous  glands,  which  disappeared  to  a  great 
extent  under  treatment  by  X-rays.  Characteristic 
smegma-like  matter  can  be  expressed  from  larger 
adenomas. 


73 


ENDOTHELIOMA  CUTIS  (0/  Skin) 
Plate  XXIX,  Fig.  39. 

Endotheliomas  (Golgi)  arise  from  the  endothelium 
of  the  blood-vessels  and  lymphatics,  which,  accord- 
ing to  Borst  consists  of  specially  modified  connective- 
tissue  cells.  Owing  to  the  double  nature  of  the  en- 
dothelium, it  is  not  surprising  that  those  who  regard 
the  endothelial  cells  as  epithelial  cells  give  the  name 
of  endothelial  cancer  or  connective-tissue  cancer  to  the 
tumors  arising  from  it,  while  others,  who  regard  the 
endothelial  cells  as  connective-tissue  cells,  call  these 
tumors  endothelial  sarcomas,  plexiform  angiosarco- 
mas {Waldeyer)  and  angiosarcoma  {KoUaczek). 

If  we  hold  with  Borst  that  the  endotheliomas  arise 
from  the  endothelium,  i.e.  from  the  connective-tissue 
cells,  which  may  assume  all  kinds  of  modifications, 
it  follows  that  tumors  of  varied  structure  may  arise 
from  these  difterent  varieties  of  endothelium,  which 
have  the  appearance  of  fibroma,  sarcoma  or  carci- 
noma, as  the  latter  forms  stratified  globes,  but  with- 
out cornification.  By  this  means  we  avoid  the  end- 
less number  of  names  given  to  these  tumors,  and  have 
clinically  only  the  term  endothelioma,  to  be  dis- 
tinguished microscopically  as  hemangio-endothelio- 
ma  and  lymphangio-endothelioma,  which  we  can 
designate  as  alveolar,  plexiform  or  vascular,  accord- 
ing to  their  microscopic  structure.  Borst  also  in- 
cludes the  basal-cell  cancers  (regarded  as  carcinoma 
by  Krompecher  and  Conen)  among  the  endotheliomas 
as  these  tumors  have  no  cornification  (cf.  Plate  II, 
Fig.  4). 

It  is  no  wonder  that  these  tumors  may  appear 
clinically  in  the  most  varied  forms  and  be  confounded 

74 


with  fibromas,  adenomas,  sarcomas  and  carcino- 
mas. 

The  tumors  may  arise  from  all  kinds  of  endothe- 
lium and  are  most  frequently  observed  in  the  skin 
of  the  face,  the  mucous  membrane  of  the  mouth  and 
pharynx,  the  bones  of  the  face  and  skull,  the  perito- 
neum, the  pia  mater  of  the  brain  and  spinal  cord, 
and  the  parotid  gland. 

Occurring  at  any  age,  they  form  encapsuled,  gen- 
erally slow-growing,  comparatively  benign  tumors 
which  seldom  cause  glandular  or  organic  metastases, 
but  have  a  tendency  to  local  recurrence. 

As  the  shape,  surface  and  consistence  of  the  tu- 
mors may  assume  all  possible  varieties,  the  clinical 
signs  of  endotheliomas  are  very  indefinite.  The 
shape  is  often  irregular,  especially  in  endothelioma 
of  the  face  (Fig.  39,  horseshoe  shape).  The  surface 
may  be  smooth,  iiTegular  or  ulcerated.  The  con- 
sistence may  be  hai'd,  soft  or  cystic.  Sometimes  the 
tumors  are  very  vascular  and  the  epidermis  assumes 
the  reddish-brow-n  coloration  which  is  seen  in 
sarcoma,  at  other  times  they  are  poor  in  vessels. 
Although  they  are  at  first  encapsuled  they  may  later 
on  give  rise  to  a  diffuse  infiltration  of  the  tissue 
along  the  endothelial  clefts,  and  then  have  irregular 
boundaries. 

Differential  Diagnosis.  Sarcoma  and  carci- 
noma are  most  often  confounded  with  endothelioma, 
also  fibroma  and  adenoma,  especially  when  they 
undergo  cystic  degeneration  or  ulceration.  The 
diagnosis  can  often  only  be  made  by  microscopic 
examination. 

Treatment.  Early  excision  is  indicated,  as  trans- 
formation is  possible  in  rapidly  growing  tumors.  In 
the  diffuse  forms,  which  represent  malignant  tumors 
like  carcinoma  and  sarcoma,  extensive  operations  are 
necessary.     When  multiple  nodules  develop  in  the 


extremities  amputation  is  sometimes  necessary.  Met- 
astases in  the  lymphatic  glands,  which  appear  in  the 
form  of  soft  nodules,  should  also  be  removed. 

Fig.  39  shows  a  horseshoe-shaped  endothelioma  of 
the  zygomatic  region,  in  an  old  woman.  The  tumor 
is  situated  in  the  skin  and  has  grown  out  of  it.  It  is 
movable  over  the  subjacent  tissues.  The  borders 
are  regular  on  all  sides.  The  skin  over  the  tumor  is 
reddish  brown  like  sarcoma,  very  thin,  and  cannot 
be  raised  from  the  tumor.  It  shows  numerous  fine 
ramifying  vessels.  In  the  middle  of  the  horseshoe  is 
an  ulcer  which  resembles  a  carcinoma  planum,  but 
the  latter,  as  previously  mentioned,  occurs  chiefly 
at  the  junction  of  skin  and  mucous  membrane. 
There  are  thus  resemblances  to  both  carcinoma 
and  sarcoma.  The  soft  borders,  the  circumscribed 
form  and  soft  consistence,  and  the  absence  of  glandu- 
lar affection,  show  the  benign  nature  of  the  tumor. 
In  endothelioma  of  the  face  the  occurrence  of  small 
multiple  cysts  in  the  cutaneous  covering  is  more  com- 
mon than  ulceration. 

Excision  of  the  tumor  and  repair  of  defect  by  a 
plastic  operation.  Microscopic  examination  showed 
it  to  be  a  plexiform  hemangio-endothelioma. 


76 


Bockenheimer,  Atlas. 


Tab.  XXX. 


Fig.  40.     Endothelioma  parotidis  —  Tumor  mixtus. 


Rebnian  Company,  New-York. 


ENDOTHELIOMA  PAROTIDIS   (of  Parotid) 
TUMOR   MEXTUS   (Mixed  Tumor) 
Plate  XXX,  Fig.  40. 

Mixed  tumors  occur  frequently  in  the  parotid, 
less  often  in  the  other  salivary  glands.  These  par- 
otid tumors  are  regarded  as  endotheliomas  by  Kanf- 
mann,  Nasse  and  Volkmann,  which  is  intelligible 
after  the  explanation  of  endothelioma  given  in  Plate 
XXIX,  Fig.  39,  if  we  assume  that  the  epithelioid 
tracts  occurring  in  the  tumors  arise  from  endothelium, 
the  latter,  according  to  Volkmann,  being  also  capable 
of  forming  cartilaginous,  mucoid  and  connective 
tissue.  Others  hold  that  these  mixed  tumors,  which 
also  occur  in  the  breast,  kidneys  and  testicles,  arise 
from  epithelial  and  connective-tissue  cells  (Wilms 
and  Hinsberg). 

On  section,  the  tumors  show  a  very  variegated 
structure,  in  which  are  found  parts  resembling  car- 
cinoma and  sarcoma,  mucoid  tissue,  cartilage,  cysts, 
calcification  and  ossification. 

Parotid  tumor  occurs  more  often  in  young  indi- 
viduals, and  appears  as  an  encapsuled,  smooth  or 
nodular  tumor,  movable  over  subjacent  parts,  lying 
under  the  fascia,  and  covered  by  intact  non-adherent 
skin.  The  rare  tumors  which  lie  above  the  parotid 
fascia  originate  in  aberrant  parotid  rudiments,  ac- 
cording to  Bergmann.  The  consistence  of  parotid 
tumors  may  be  hard,  soft  or  cystic,  according  to  their 
composition,  and  may  differ  in  different  parts  of  the 
same  tumor.  At  first  they  are  of  slow  growth,  but 
may  suddenly  take  on  rapid  growth,  rupture  their 
capsule,  infiltrate  the  surrounding  parts  like  malig- 
nant tumors,   and    finally   perforate    the    skin    and 

77 


ulcerate.  In  such  cases  there  are  glandular  and 
organic  metastases. 

Tumors  arising  from  the  anterior  part  of  the 
parotid  cause  swelling  of  the  cheek;  those  arising 
from  the  posterior  part  of  the  gland  raise  up  the 
external  ear.  Larger  tumors  may  extend  towards 
the  chin,  the  nape  of  the  neck  and  the  clavicle. 

Small  tumors  cause  hardly  any  pain,  but  some- 
times salivation.  Extensive  tumors  may  give  rise  to 
pain  in  the  ear,  deafness  and  facial  paralysis. 

Differential  Diagnosis.  The  more  common  car- 
tilaginous tumors  with  uneven  surface  are  easy  to  dis- 
tinguish from  other  growths,  but  the  soft  tumors  with 
smooth  surface  may  be  confounded  with  lymphomas, 
cavernomas,  lipomas  and  cysts.  Extensive  endothe- 
liomas are  often  indistinguishable  from  sarcomas  or 
carcinomas. 

Mixed  tumors  should  be  extirpated  as  early  as 
possible,  on  account  of  the  possibility  of  their  taking 
on  malignant  growth.  Both  benign  and  malignant 
recurrence  may  take  place  from  the  remains  of  the 
capsule  after  removal  of  tumor.  The  capsule  must, 
therefore,  be  completely  removed  during  extirpation, 
taking  care  to  avoid  large  branches  of  the  facial 
nerve,  while  the  part  of  the  gland  which  is  unaffected 
can  be  left  behind.  In  extensive  malignant  endothe- 
liomas of  the  parotid  it  is  hardly  possible  to  save  the 
facial  nerve,  for  in  these  cases  the  whole  gland  must 
be  removed.  In  tumors  of  the  submaxillary  gland 
the  whole  gland  should  always  be  removed. 

Fig.  40  shows  a  mixed  tumor  of  the  parotid  which 
slowly  developed  during  three  years  in  a  woman 
aged  thirty.  Profuse  salivation,  and  latterly  rapid 
growth  of  the  tumor,  led  the  patient  to  seek  advice. 
The  skin  is  freely  movable  over  the  tumor  and  shows 
a  fine  network  of  vessels.  The  tumor  lies  under  the 
fascia  and  has   spread   to   the   anterior   and   lower 

78 


region  of  the  ear.  The  surface  of  the  tumor  is  irregu- 
lar; the  consistence  of  the  posterior  portion,  where 
the  surface  is  uneven,  is  hard;  soft  and  fluctuating  in 
the  anterior  portion,  where  the  surface  is  smooth. 
There  is  no  projection  of  the  tumor  into  the  buccal 
cavity.  The  tumor  is  freely  movable  over  the  sub- 
jacent parts,  and  there  is  no  glandular  enlargement. 
The  tumor  was  extirpated  with  its  capsule,  and 
the  facial  nerve  avoided.  Part  of  the  parotid  gland 
was  left  behind.  On  section,  cartilage,  cysts,  calcifi- 
cation, and  fibrous  and  sarcomatous  tissue  were 
found. 


79 


GANGLION  CARP  ALE  {of  Wrist) 
Plate  XXXI,  Fig.  41. 

Ganglions  occur  especially  in  connection  with  the 
joints  of  the  hand,  most  often  on  the  dorsal  surface 
between  the  extensor  carpi  radialis  and  extensor 
indicis,  less  commonly  on  the  palmar  side  near  the 
flexor  carpi  radialis  (especially  in  pianists);  also  on 
the  dorsum  of  the  foot  at  the  joints  of  the  cuboid 
bone  and  in  the  neighborhood  of  the  knee  joint. 

Colloid  degeneration  of  the  joint  capsule  and  the 
periarticular  connective  tissue  gives  rise  first  to  mul- 
tilocular,  then  unilocular  cystomas,  which  were  for- 
merly regarded  as  retention  cysts.  Ganglions  of  the 
tendon  sheaths  arise  in  a  similar  manner,  but  are 
smaller;  they  occur  chiefly  in  the  sheaths  of  the 
flexor  tendons  over  the  metacarpo-phalangeal  joints, 
and  cause  neuralgic  pain  by  pressure  on  the  digital 
nerves.  They  often  occur  after  rowing  and  fencing, 
i.e.  from  traumatic  causes. 

Spherical  ganglia  occur  most  commonly  on  the 
dorsal  aspect  of  the  hand  in  young  women,  and  re- 
semble exostoses  on  account  of  their  hardness. 
They  often  cause  neuralgic  pains  and  slight  trouble 
in  the  movements  of  the  joints. 

Ganglions  are  of  slow  growth,  the  skin  is  unaltered 
and  movable  over  them;  the  surface  is  smooth  or 
slightly  wrinkled.  The  consistence  is  hard  in  small 
ganglions,  soft  and  fluctuating  in  larger  ones.  In 
pedunculated  ganglions  there  is  slight  mobility  over 
the  joint. 

Differential  Diagnosis.  In  the  knee  joint  they 
may  be  mistaken  for  affections  of   burste;    in   the 

80 


Bockenheinier,  Atla?. 


Tab.  XXXI. 


r, 


Rfbnian  Company,  New-York. 


foot  for  ganglions  of  the  tendon  sheath.  Tubercu- 
lous teno-synovitis  is  distinguished  by  its  nodular 
surface  and  by  spreading  along  the  tendons. 

Treatment.  They  may  be  cured  by  breaking 
them  with  a  wooden  hammer  and  then  compressing 
with  a  bandage.  Subcutaneous  discission,  puncture, 
injection  of  alcohol,  etc.,  and  even  incision  do  not 
always  prevent  recurrence.  A  permanent  cure  can 
be  obtained  by  extirpation  of  the  ganglion  with 
its  pedicle.  This  involves  opening  the  joint,  with 
which  they  often  communicate,  or  are  only  separated 
from  it  by  a  thin  membrane;  hence  strict  asepsis  is 
necessary. 

Fig.  41  shows  a  ganglion  in  a  typical  situation  in  a 
young  girl,  which  recurred  after  being  broken. 
Extirpation  of  the  ganglion  resulted  in  cure.  The 
unilocular  cyst  contained  colloid  matter.  The  pres- 
ence of  septa  gave  evidence  of  an  earlier  multilocular 
structure. 


81 


BURSITIS  PRAEPATELLARIS  ACUTA 

(Acute  prepatellar  Bursitis) 
Plate  XXXI,  Fig.  42. 

Affections  of  the  bursse  may  be  divided  into  acute 
and  chronic  inflammations,  and  further  into  purulent 
and   non-purulent  (serous,  fibrinous,   hemorrhagic). 

An  acute  bursitis  occurs  especially  after  injuries 
and  inflammation  extending  from  neighboring  regions 
(furunculosis,  arthritis).  It  may  also  arise  from  for- 
eign bodies  inside  the  bursa. 

In  acute  serous  bursitis  the  skin  is  unchanged, 
while  in  purulent  bursitis  it  is  red  and  oedematous. 
In  the  latter,  suppuration  often  extends  beyond  the 
limits  of  the  bursa  and  is  accompanied  by  fever, 
pain  and  difiiculty  in  movement.  Under  the  mova- 
ble skin,  in  the  case  of  superficial  burste  {e.g.  the 
prepatellar),  a  hemispherical,  tense,  sometimes  fluc- 
tuating, slightly  movable  swelling  with  a  smooth 
surface  can  be  felt,  limited  to  the  anatomical  position 
of  the  bursa  (Fig.  42). 

Chronic  bursitis,  also  called  hygroma,  occurs  more 
after  chronic  irritation,  in  the  prepatellar  bursa,  in 
housemaids,  for  instance  (housemaid's  knee),  and 
in  the  olecranon  bursa  in  miners  (miner's  elbow). 
Villous  proliferations  in  the  wall  of  the  bursa  lead 
to  thickening,  and  to  the  formation  of  rice  bodies. 
The  skin  over  the  bursa  is  movable  and  thickened. 
The  hygroma  is  almost  spherical,  with  a  rough, 
uneven  surface. 

Hygroma  may  also  develop  in  adventitious  bursse, 
especially  in  places  where  a  bone  is  subjected  to 
pressure,  for  instance,  on  the  toe  over  a  clavus. 
Hygromas  give  rise  to  little  inconvenience,  and  only 

82 


hinder  movement  when  of  large  size.  In  the  case  of 
the  elbow  there  is  sometimes  neuralgic  pain  from 
pressure  on  the  ulnar  nerve. 

Differential  Diagnosis.  The  different  forms  of 
bursitis  may  be  mistaken  for  arthritis  of  the  adjacent 
joint,  owing  to  limitation  of  movement,  e.g.  sub- 
deltoid and  sub-trochanteric  bursitis.  The  strict 
localization  of  the  affection  to  the  anatomical  position 
of  the  bursse  should  make  the  diagnosis  easy.  Dis- 
ease of  several  bursas  is  chiefly  obser\'ed  in  tuber- 
culosis, syphilis,  gonorrhea  and  gout. 

Treatment.  Acute  purulent  bursitis  requires 
early  incision  and  plugging,  as  infection  of  the  joint 
may  take  place.  In  acute  serous  or  hemorrhagic 
effusion,  puncture  and  injection  of  4  per  cent,  car- 
bolic lotion,  1  per  cent,  iodoform-glycerin  or  abso- 
lute alcohol  may  be  tried.  In  chronic  bursitis,  paint- 
ing with  iodine  is  generally  useless.  It  is  best  to 
extirpate  chronic  hygromas,  especially  when  they  are 
large  or  have  thick,  hard  walls,  or  when  fistulte 
develop,  taking  care  to  avoid  the  joints. 

Fig.  42  shows  an  acute  purulent  prepatellar  bur- 
sitis. The  skin  is  red  and  hot  and  the  movements  of 
the  knee  joint  are  painful  and  limited.  The  tense, 
fluctuating,  spheroidal  swelling  is  clearly  situated  in 
front  of  the  patella.  The  surface  is  smooth  and  reg- 
ular, but  the  tumor  is  almost  immovable  over  the 
subjacent  structures.  It  was  shown  by  incision  that 
all  three  bursa? — subcutaneous,  subfascial  and  sub- 
aponeurotic—were  full  of  pus  and  in  communication 
with  each  other. 


83 


HYGROMA  GENUS  MULTILOCULARE 

(Multilocular  Hygroma  of  the  Knee) 

BURSITIS  PRAEPATELLARIS  ET  BURSITIS  PRAETIBIALIS 

{Prepatellar  and  Pretibial  Bursitis) 
Plate  XXXII,  Fig.  43. 

This  figure  shows  a  case  of  chronic  inflammation 
of  the  prepatellar  bursa  and  the  lower  half  of  the 
pretibial  bursa,  occurring  in  a  man  who  had  to  do 
his  work  in  the  kneeling  position.  The  skin  over 
the  prepatellar  bursa  is  thickened  and  movable  over 
the  cystic  swelling.  The  walls  of  both  hygromas  are 
thickened.  They  are  only  slightly  movable  over  the 
subjacent  structures.  Pressure  on  one  hygroma 
causes  some  of  its  fluid  to  pass  into  the  other,  so 
that  the  two  bursse  communicate.  Total  extirpation 
was  performed  owing  to  the  extent  of  the  hygroma 
and  the  thickened  walls. 


84 


Bockenheinier,  Atlas 


Tab.  XXXII. 


Fig.  43.    Hygroma  genus  miiltilociilaiT. 


Rebm;in  Coniti.Tiiv    Mpvp-Vcirlt. 


Bockenheimer,  Atlas. 


Tab.  XXXIII. 


u^ 


Rebman  Company,  New- York. 


STRUMA  CYSTICA  (Brmchocek) 
Plate  XXXIII,  Fig.  44. 

Goitre  occurs  endemically  (Switzerland  and  other 
regions)  and  epidemically  in  barracks  and  boarding 
houses  (Strumitis  acuta  first  observed  by  Kussmaul). 
Heredity,  frequent  congestion  of  the  blood-vessels  of 
the  head,  pregnancy,  the  nature  of  the  soil,  water  and 
atmosphere  have  all  been  suggested  as  causes  of 
bronchocele. 

Bronchoceles  occur  twice  as  often  in  females  as 
in  males  (Schrotter).  Clinically,  they  are  divided 
into  diffuse  and  circumscribed  forms,  and  patho- 
logically into  follicular,  colloid,  vascular  and  cystic 
bronchoceles. 

In  all  cases  the  typical  situation  corresponds  to 
the  anatomical  position  of  the  thyroid  gland,  and 
the  symptoms  are  definite.  Even  small  bronchoceles 
cause  marked  and  early  deformity.  Further  exten- 
sion results  in  pressure  on  the  veins,  causing  promi- 
nence of  the  cutaneous  veins  and  a  cyanotic  appear- 
ance of  the  face.  Pressure  on  the  trachea  may  give 
rise  to  displacement,  stricture  and  changes  in  its 
walls,  causing  it  to  assume  the  form  of  a  saber- 
sheath.  This  dangerous  condition  can  be  seen  by 
the  X-rays.  Eventually  the  wall  of  the  trachea  may 
become  so  much  destroyed  as  to  give  way  after 
violent  movement  of  the  head.  Difficulty  in  breath- 
ing during  inspiration,  causing  stridor,  is  the  neces- 
sary result,  and  sudden  asthmatic  attacks,  occurring 
during  violent  movements  of  the  patient  or  during 
sleep  may  prove  fatal.  Pressure  on  one  recurrent 
nerve  is  of  little  consequence  and  often  unnoticed,  for 
unilateral  paralysis  of  the  recurrent  is  compensated, 

85 


so  that  hoarseness  is  often  absent,  and  the  condition 
is  only  shown  by  laryngoscopic  examination.  Bilat- 
eral paralysis  of  the  reeurrents  is,  however,  very 
dangerous,  as  it  may  give  rise  to  asphyxia  or  pneu- 
monia. Small  fibrous  tumors  arising  in  the  middle 
line  from  the  isthmus  of  the  thyroid,  and  those 
lying  behind  the  sternum  cause  more  characteristic 
symptoms  than  large,  soft  tumors,  which  often  cause 
little  trouble. 

Every  bronchocele  moves  with  the  thjToid  on  swal- 
lowing and  is  thus  distinguished  from  other  affections. 

The  simplest  form  of  bronchocele,  which  consists 
in  a  hypersemia  of  the  whole  organ,  is  common  in 
young  girls  at  the  onset  of  menstruation,  or  at  the 
first  sexual  intercourse,  and  appears  as  a  soft,  uni- 
form swelling  of  the  whole  gland,  which  may  disap- 
pear spontaneously. 

According  to  v.  Eiselsberg,  this  simple  form  may 
often  give  rise  to  follicular  hypertrophy.  The  latter 
also  occurs  in  young  individuals  in  the  form  of  hard 
nodules  in  the  gland,  which  may  also  disappear. 

More  marked  enlargement  of  the  thyroid  gland, 
developing  gradually  in  middle  age,  and  leading  to 
the  formation  of  a  horseshoe-shaped  tumor  involving 
the  whole  gland  and  consisting  of  a  number  of  large 
nodules,  is  diagnostic  of  colloid  bronchocele,  while 
the  vascular  bronchocele  is  characterized  by  pulsa- 
tion and  compressibility.  The  cystic  bronchocele 
(Fig.  43),  arising  from  several  colloid  nodules  owing 
to  hemorrhage  and  liquefaction,  forms  small,  hemi- 
spherical tumors  with  a  smooth  surface  and  distinct 
fluctuation.  When  the  cyst  walls  are  hardened  by 
calcification  the  diagnosis  is  more  difficult,  but 
differs  from  the  irregular,  nodular  formation  of 
■fibrous  bronchocele.  Cystic  bronchoceles  may  attain 
the  size  of  a  man's  head. 

The  different  varieties — colloid,  cystic,  vascular 
and  fibrous — may  all  occur  in  the  same  tumor. 

The  diagnosis  of  the  different  kinds  of  bronchocele 

86 


is  important  with  regard  to  treatment,  which  should 
be  begun  early,  as  cardiac  symptoms  occur  iu  con- 
nection with  long-standing  large  bronchoceles. 

Differential  Diagnosis.  An  accessory  broncho- 
cele  is  easily  diagnosed  when  it  is  fixed  to  the  thyroid 
by  a  pedicle,  as  it  then  gives  rise  to  the  same  symp- 
toms. Bronchoceles  which  arise  from  free  accessory 
glands  may  be  mistaken  for  other  tumors  of  the  neck 
— lymphoma,  sebaceous  cyst,  dermoid  or  malio-- 
nant  tumor. 

Carcinoma  of  the  thyroid  gland  occurs  in  old 
people  and  forms  a  nodular,  very  hard,  rapidly 
growing  tumor,  which  soon  surrounds  the  whole  neck 
with  a  hard  ring.  The  diagnosis  is  settled  by  the 
glandular  metastases,  the  early  appearance  of  paraly- 
sis of  the  vocal  cords  and  cachexia.  In  old  people, 
the  sudden  occurrence  of  rapid  growth  in  an  old- 
standing  bronchocele  always  suggests  malignant 
transformation. 

Sarcomas,  which  occur  in  young  people  as  rapidly 
growing  tumors,  are  distinguished  by  their  soft 
consistence  and  by  their  diffuse  infiltration.  They 
often  break  through  the  capsule  and  give  rise  to 
severe  hemorrhage. 

Basedow's  disease  (Grave's  disease,  exophthalmic 
goitre),  which,  according  to  Mobiiis,  consists  iu 
hypersecretion  of  the  thyroid  gland  resulting  in  intox- 
ication of  the  organism,  is  distinguished  from  ordi- 
nary bronchocele  by  the  presence  of  tachycardia, 
tremor,  exophthalmus  and  neuropathic  conditions. 
The  swelling  in  Basedow's  disease  is  always  very 
vascular  and  often  pulsates.  In  long-standing  bron- 
choceles symptoms  of  Basedow's  disease  may  appear, 
but  they  are  never  so  marked  as  in  the  genuine  form; 
all  the  other  characteristic  symptoms  of  bronchocele 
are  also  present. 

Mediastinal  tumors  and  aneurisms  are   occasion- 
ally mistaken  for  retrosternal  bronchocele. 


Treatment.  The  treatment  varies  according  to 
the  nature  of  the  bi'onchocele. 

In  countries  where  goitre  is  epidemic,  prophylaxis 
plays  the  chief  role.  Water  should  only  be  drunk 
after  boiling.  Violent  exertion  should  be  avoided, 
on  account  of  causing  a  determination  of  blood  to 
the  head. 

In  acute  hyperaemia  and  follicular  hypertrophy 
iodine  preparations  are  most  useful  —  iodide  of 
potassium,  or  thyroid  tabloids  containing  iodine 
(to  be  given  carefully  on  account  of  tachycardia). 
Iodine  preparations  should  not  be  continued  too 
long. 

In  cystic  and  colloid  bronchoceles  iodine  treatment 
gives  no  results,  and  operation  is  indicated — partial 
extirpation  in  the  case  of  colloid  bronchocele.  Suffi- 
cient thjToid  gland  tissue  must  be  left  otherwise 
tetania  strumipriva  or  m;yxoedema  may  follow. 

Cretinism,  which  is  only  observed  in  countries 
where  goitre  is  endemic,  and  causes  changes  in  the 
skin,  disturbance  in  growth  and  idiocy,  is  also  due 
to  degeneration  of  the  greater  part  of  the  thyroid 
eland  or  absence  thereof  in  the  cretins  themselves  or 
in  their  parents. 

In  post-operative  tetany,  cachexia  strumipriva, 
mj^oedema  and  cretinism,  implantation  of  a  piece 
of  human  thyroid  gland  in  the  diseased  subject  may 
be  attempted  {Kohn,  v.  Eiselsherg,  et  al.).  It  is 
best  to  transplant  a  large  piece  into  the  spleen 
{Payr). 

Isolated  cysts  and  nodules  can  be  enucleated. 
Recurrence  after  operation  is  rare  on  the  whole  and 
then  usually  causes  no  trouble. 

In  Basedow's  disease  ligation  of  the  superior  and 
inferior  th}Toid  arteries  has  been  successfully  tried. 
{Rehn,  v.  Bergmann).  The  operation  is  not  without 
danger,  so  that  others  have  preferred  internal  treat- 
ment with  arsenic,  or  by  the  galvanic  current,  etc., 
often  successfully. 


Fig.  43  shows  a  tumor  the  size  of  a  walnut,  in  an 
old  woman,  which  is  easily  recognized  as  a  cystic 
bronchocele  by  its  rounded  form,  regular  outline, 
situation  in  the  isthmus  of  the  thyroid  and  its  move- 
ment during  swallowing.  The  tumor  was  enucleated 
on  account  of  its  causing  considerable  difficulty  in 
respiration. 


89 


PAPILLOMA  CUTIS  INFLAMMATORIUM 

{Inflammatory  Papilloma  of  Skin) 
Plate  XXXIV,  Fig.  45. 

Papillomas  or  villous  tumors,  also  occurring  on 
mucous  membranes  as  villous  polypi,  belong  to  the 
group  of  fibro-epithelial  tumors  (Borst).  They  con- 
sist of  vascular  connective  tissue  and  epithelial 
proliferation  (squamous  moi-e  often  than  cylindrical) 
and  simulate  in  structure  the  papillae  of  the  skin  and 
mucous  membrane.  These  growths  represent  a  spe- 
cial group  of  tumors,  and  must  not  be  confounded 
with  papillomatous  proliferations  found  in  a  similar 
form  in  ntevi,  carcinomas,  sarcomas  and  endothelio- 
mas. Condylomata  acuminata  are  also  very  similar 
to  papilloma;  however,  these  are  not  true  tumors, 
but  are  due  to  hyperplasia  of  the  papillary  body  and 
its  epithelial  covering.  These  generally  occur  as  the 
result  of  chronic  inflammatory  irritation  from  gon- 
orrheal discharge,  on  the  penis,  vagina  and  anus. 

True  papillomas  generally  form  small  superficial 
tumors  of  a  warty  or  conical  form,  single  or  multiple, 
occurring  at  any  age,  in  places  exposed  to  much  irri- 
tation (skin,  genitals,  thighs,  back,  tongue,  rectum, 
bladder  and  larynx).  They  are  slow-growing,  cir- 
cumscribed, sessile  or  pedunculated,  freely  movable, 
non-infiltrating  growths.  Papillomas  of  the  skin  are 
yellowish-white  dry  growths,  hard  from  cornification 
of  the  superficial  epithelial  layers,  and  form  conical 
or  wart-like  projections. 

Papillomas  of  the  mucous  membrane  have  a  red- 
dish fleshy  appearance,  and  on  account  of  their  vas- 
cularity, bleed  easily  and  are  of  soft  consistence.  In 
the  larynx,  they  occur  especially  in  the  region  of  the 

90 


Bockenheimer,  Atlas. 


Tah.  XXXIV. 


["ig.  45.     Papilloma  cutis  inflammatorium. 


Rchmnn  Pnmnanv     Ncvr.VnrV. 


vocal  cords;  they  are  often  multiple  in  young  indi- 
viduals, prone  to  recur,  and  may  lead  to  stenosis. 
Transition  into  carcinoma  may  occur,  and  is  recog- 
nized by  rapid  growth,  ulceration,  infiltration,  and 
growth  into  the  deeper  parts. 

Differential  Diagnosis.  Small  papillomas  of 
the  skin  may  be  mistaken  for  common  warts.  In  dis- 
tinction to  carcinoma  they  present  the  usual  charac- 
teristics of  benign  tumors — soft  consistence,  free 
mobility,  and  no  glandular  metastases.  Papillomas 
of  mucous  membranes  are  usually  characteristic  for- 
mations. It  is  only  in  villous  polypi  of  the  bladder, 
which  may  become  transformed  into  villous  cancer, 
that  the  diagnosis  is  difficult. 

Treatment.  Excision.  Extensive  operations  are 
often  necessary  for  the  removal  of  papillomas  of  the 
mucous  membranes  (tracheotomy,  colostomy,  etc.). 

Fig.  45  shows  a  cutaneous  papilloma,  freely  mova- 
ble over  subjacent  parts,  of  moderately  soft  consist- 
ence, and  covered  with  warty  projections.  The 
horny  layer  and  the  surface  of  the  skin  has  been 
destroyed  by  frequent  cauterization.  The  surface  is 
covered  with  a  yellowish  fetid  secretion,  and  between 
the  villous  projections  are  deep  depressions  caused  by 
ulceration,  so  that  the  appearance  in  some  places 
resembles  carcinoma;  but  the  borders  are  not  hard. 
The  skin  round  the  tumor  is  red  and  painful  from 
cauterization. 

After  disinfection  of  the  surface  and  arrest  of  the 
discharge,  the  tumor  was  excised  in  healthy  tissue 
and  the  wound  closed  by  suture. 


91 


Dermoids 

RECURRENT  DERMOID 

Plate  XXXV,  Fig.  46. 
DERMOID— PHIMOSIS— BALAIHTIS 

Fig.  47. 
DERMOID  CYST 

Plate  XXXVI,  Fig.  48. 

True  dermoid  cysts  are  formed  from  the  epiblast 
only,  while  compound  dermoid  cysts  include  all  three 
embryonic  layers.     (Teratoma,  Fig.  146). 

As  pure  dermoid  cysts  arise  through  invagination 
of  the  epiblast  they  must  be  congenital,  and  can  only 
occur  where  there  were  folds,  furrows  or  recesses  in 
embryonic  life,  or  in  places  where  organs  are  devel- 
oped by  invagination  of  the  epiblast.  These  tumors 
are,  therefore,  of  embryonic  formation. 

Dermoid  cysts  occur  in  the  cutaneous  and  sub- 
cutaneous tissue  in  the  region  of  the  head  (occipital, 
parietal  and  temporal  bones);  in  the  region  of  the 
face  (root  of  the  nose  and  orbit);  in  the  neck  (re- 
mains of  branchial  clefts) ;  at  the  umbilicus ;  and  in 
the  coccygeal  region  as  fissural  dermoid  cysts.  The 
occurrence  of  dermoids  in  the  cranial  cavity,  verte- 
bral canal,  thoracic  cavity,  abdominal  cavity,  retro- 
peritoneal tissue,  kidneys  {Wolffian  duct)  is  explained 
by  the  development  of  organs  by  invagination  of  the 
epiblast. 

Dermoid  cysts  of  the  testicles  and  ovaries,  on 
account  of  their  complicated  structure,  are  not 
pure  dermoids. 

Pure  dermoids  are  unilocular  or  multilocular  cysts, 
the  external   walls   of  which   consist  of   connective 

92 


Bockenheimer,  Atlas. 


Tab.  X.WV, 


Fig.  46.     Dermoid       Recidi 


Fipr.  47.     DcrniDiil        ^'llilH()^i^. 


tissue,  and  are  connected  with  the  surroundintr  tis- 
sues  while  the  internal  surface  resembles  skin 
(hence  the  term  dermoid),  and  presents  papilla^, 
squamous  epithelium  and  hair.  Those  dermoids 
which  contain  bone,  cartilage  and  teeth  are  formed 
at  a  very  early  embryonic  period,  before  differentia- 
tion has  taken  place. 

The  contents  of  the  cyst  consist  of  a  yellowish- 
white,  caseous,  odorless,  fatty  mass,  mixed  with 
numerous  hairs,  the  appearance  of  which  varies 
according  to  the  situation  of  the  dermoid  (in  the 
region  of  the  eye,  eyelashes,  etc.).  The  contents 
are  rarely  serous  or  hemorrhagic.  In  the  cutaneous 
or  subcutaneous  tissue  the  cysts  form  spherical  or 
hemispherical  tumors  with  a  smooth  surface  and 
tallowy  consistence.  They  are  covered  by  intact 
skin,  and  are  often  attached  to  the  bones.  The  super- 
ficial dermoids  usually  occur  in  youth.  They  are 
slow-growing  and  painless,  and  about  the  size  of  a 
walnut.  Sometimes  fistulfe  form  from  which  hairs 
protrude.  The  diagnosis  of  superficial  dermoids  is 
easy  to  establish  by  the  above  signs. 

Differential  Diagnosis.  Superficial  dermoids 
may  be  mistaken  for  sebaceous  cysts,  but  the  con- 
tents of  the  latter  are  foul  smelling  and  more  dirty 
yellow.  If  scars  are  present  (e.g.  after  operations, 
Fig.  46),  the  history  or  microscopic  examination  only 
can  decide  whether  it  is  a  traumatic  (post  embryonic) 
formation  caused  by  proliferation  of  an  involuted 
part  of  the  skin — the  so-called  epithelial  cysts. 
These  may  also  form  round  a  foreign  body.  Epider- 
moids can  often  only  be  distinguished  from  dermoids 
microscopically,  the  former  being  lined  with  squam- 
ous epithelium,  but  containing  no  sebaceous  or  sweat 
glands  or  hair.  At  the  root  of  the  nose  there  is  a 
similarity  to  encephalocele  (Fig.  46).  In  the  neck, 
dermoids  may  be  mistaken  for  lipomas,  lymphomas 
and  branchiogenous  cysts. 

93 


Dermoids  of  the  umbilicus,  on  account  of  their 
hardness,  may  be  mistaken  for  malignant  tumors, 
but  they  are  of  slow  growth  and  circumscribed. 
Dermoids  of  the  abdominal  walls  are  often  mistaken 
for  sarcomas  and  fibromas,  but  the  latter  are  rapidly 
growing  tumors,  and  often  not  encapsuled. 

Deeply  situated  dermoids  of  the  various  cavities 
and  organs,  which  are  often  only  noticed  accidentally, 
cannot  as  a  rule  be  distinguished  from  other  tumors. 


'&^ 


Treatment.  Extirpation  of  the  whole  cyst  is  nec- 
essary, as  recurrence  takes  place  if  any  part  is  left 
behind.  Commencing  carcinoma  has  been  observed 
in  the  inner  surface  of  the  cyst  wall  (Wolff). 

Fig.  46  shows  a  dermoid  of  the  forehead,  where 
it  is  often  observed,  either  above  the  root  of  the  nose, 
the  inner  angle  of  the  eye,  or  laterally  near  the 
glabella  (fissural  dermoid  cyst).  The  skin  is  mova- 
ble over  the  tumor,  which  was  observed  in  early 
youth,  and  shows  a  small  white  scar  left  by  a  former 
insufficient  operation.  The  surface  of  the  tumor  is 
smooth  and  hemispherical.  At  the  periphery  there 
are  raised  bony  walls.  The  tumor  slowly  attained 
its  present  size  after  the  former  operation  and  then 
reinained  stationary.  There  is  no  diminution  on 
pressure  over  the  tumor.  It  is  of  doughy  consistence 
and  only  slightly  movable  over  the  subjacent  bone. 

Lipomas  occurring  on  the  forehead  and  having  a 
smooth,  not  lobulated  surface,  may  resemble  der- 
moids. However,  they  are  not  congenital,  have  no 
bony  ring  round  them,  and  are  freely  movable. 

Encephalocele  (which  may  be  naso-frontal,  naso- 
ethmoidal, or  naso-orbital)  is  also  a  congenital  tumor, 
but  generally  attains  a  much  larger  size,  diminishes 
on  pressure,  and  has  no  bony  ring  round  it. 

On  account  of  the  scar  in  the  skin  an  epithelial 
cyst  might  be  thought  of;  however,  this  is  not  con- 
genital but  occurs  later  as  the  result  of  trauma. 

94 


Bockeiilieimer,  Atlas. 


Tab.  XXXVl. 


Fifj.  48.     Dermoid  —  Cvstis. 


Rcbiiiaii  Company,  Nevr-York. 


Sebaceous  cysts  are  recognized  by  their  superficial 
position  in  the  skin. 

This  case  was  cured  by  extirpation. 

Fig.  47  shows  a  dermoid  of  the  prepuce,  situated 
symmetrically  on  both  sides  of  the  raphe,  and  present 
since  birth.  The  skin  is  so  thin  that  the  contents 
can  be  seen  through  it.  The  tumor  has  caused  phi- 
mosis and  balanitis. 

Fig.  48  shows  a  dermoid  of  the  neck  in  the  position 
of  the  second  branchial  arch.  Symmetrical  der- 
moids in  the  middle  line  may  occur  above  or  below 
the  larynx.  Dermoids  of  the  floor  of  the  mouth  may 
cause  bulging  of  the  sub-mental  region.  The  tumor 
is  the  size  of  a  hen's  egg,  has  a  smooth  surface,  is  of 
doughy  or  semi-fluctuating  consistence,  movable  over 
subjacent  parts  and  covered  by  movable,  intact  skin. 
It  was  present  since  infancy,  at  first  slow-growing, 
later  on  stationary,  and  caused  no  inconvenience 
apart  from  the  disfigurement. 

It  was  possible  to  mistake  this  tumor  for  a  tubercu- 
lous lymphoma,  or  a  thyro-glossal  C5'st,  but  the 
doughy  consistence  settled  the  diagnosis.  Treated 
by  extirpation. 


95 


FIBROMA   VAGINAE   TENDONIS   {Fibroma  of  Tendon-Sheath) 
Plate  XXXVII,  Fig.  49. 

Fibroma  belongs  to  the  benign  connective-tissue 
tumors,  and  consists  of  connective-tissue  cells,  fibril- 
lar, inter-cellular  substance  and  a  variable  amount 
of  blood-vessels  and  lymphatics.  When  the  matrix 
is  hard  and  abundant,  with  slight  development  of 
spindle-cells,  the  fibroma  is  hard,  while  soft  fibroma 
is  formed  by  spongy  tissue  with  numerous  blood- 
vessels. 

Fibromas,  which  consist  of  fibrous  connective  tis- 
sue with  few  nuclei,  are  also  termed  desmoids,  and 
occur  especially  in  the  fascia  of  the  abdominal  walls, 
while  the  term  fibrosarcoma  is  applied  to  tumors 
which  consist  of  irregularly  arranged  spindle  cells 
with  little  intercellular  substance,  and  show  degen- 
erative changes  and  an  absence  of  mature  tissue. 

Transitional  forms  from  fibroma  to  fibrosarcoma 
and  sarcoma  are  especially  observed  in  the  tumors 
occurring  in  fascia.  Mixed  forms  are  often  found, 
such  as  fibro-lipoma,  fibro-myoma,  fibro-adenoma 
and  fibro-myxoma.  Cystic  formation  is  also  seen 
in  fibromas. 

Fibromas  occur  in  all  situations  where  fibrillar 
connective  tissue  is  present — in  the  cutaneous  and 
subcutaneous  tissue  (back  and  thigh),  in  intermus- 
cular, intertendinous  (Fig.  49),  submucous  and 
subserous  tissue  (alimentary  canal,  uterus,  larynx). 
They  may  also  develop  in  fasciae  and  aponeuroses, 
nerve  sheaths  and  periosteum  (naso  -  pharyngeal 
tumors,  Fig.  25,  and  epulis.  Fig.  35),  and  also  in 
the  organs. 

96 


Bockeiilieiiiier,  Atlas. 


Tab.  XXWl 


iJD 


':^ 


p 
3 


ti 


They  form  circumscribed  tumors  of  firm  consist- 
ence and  smooth  surface,  often  encapsuled,  slow- 
growing,  sessile  or  pedunculated  (fibrolipoma  pendu- 
lum, Fig.  52).  Pedunculated  submucous  fibromas 
often  occur  in  the  laiynx  in  singers.  Fibromas  form 
rounded  or  polypoid  growths,  which  may  occur  at 
any  age,  but  are  seldom  congenital.  After  meta- 
plastic changes  (ossification)  they  may  become  hard 
tumors. 

In  the  skin  and  subcutaneous  tissue  they  have  a 
yellowish-white  surface  (Fig.  49).  On  section  they 
show  stratification  and  a  glistening  appearance  like 
tendon. 

Differential  Diagnosis.  Superficial  hard  fibro- 
mas of  the  skin  and  subcutaneous  tissue  are  easily 
recognized  by  their  form,  consistence,  clear  demarca- 
tion and  solitary  appearance.  It  is  only  transitional 
forms  between  fibrosarcoma  and  sarcoma  that  pre- 
sent any  difficulty.  Deep  fibromas  which  often 
attain  a  large  size  {e.g.  in  the  abdominal  cavity)  are 
recognized  by  their  nodular  surface,  hardness  and 
encapsulation. 

Treatment.  Excision  of  the  tumor  with  its  cap- 
sule. For  the  removal  of  deep  fibromas  extensive 
operations  are  necessary.  Sometimes  they  are  so 
firmly  attached  to  the  neighboring  tissues  or  organs 
that  a  portion  of  the  latter  must  be  removed  with 
them. 

Fig.  49  shows  a  fibroma  of  the  sheath  of  the  flexor 
tendon  of  the  finger,  the  yellowish-white  surface  of 
which  shows  through  the  skin.  The  skin  is  slightly 
movable  over  the  hard  nodular  tumor.  The  tumor 
itself  is  movable  over  the  subjacent  structures,  and 
remains  unaltered  in  position  on  moving  the  finger. 
Fibromas  of  tendon  sheaths  are  rare  on  the  whole, 
and  are  due  to  traumatic  causes.  The  tumor  was 
excised. 

97 


After  injuries  and  stretching  of  tendons  similar 
growths  occur,  sometimes  multiple;  they  are  due  to 
proliferation  of  the  cellular  tissue.  In  Dupuytrens 
contraction  (Fig.  60)  nodules  also  develop  in  the 
palmar  aponeurosis,  which  have  a  resemblance  to 
fibromas. 

Thickenings  which  occur  in  tendons  and  tendon 
sheaths,  and  lock  the  movements  of  the  fingers  in 
certain  positions,  are  not  true  fibromas. 


98 


CHONDROMA 
Plate  XXXVII,  Fig.  50. 

Although  cartilaginous  tumors  are  pathologically 
divided  into  two  groups:  (1)  ecchondromas,  or  hyper- 
plastic proliferations  from  pre-existing  cartilage,  which 
only  occur  in  places  where  cartilage  is  usually  pres- 
ent; (2)  heteroplastic  cartilaginous  growths,  or  en- 
chondromas,  which  occur  in  places  where  cartilage 
is  not  normally  present;  these  two  forms  are  often 
impossible  to  distinguish  clinically. 

We,  therefore,  include  both  forms  under  the  name 
of  chondroma.  The  tumors  either  consist  of  the 
diflferent  forms  of  cartilage,  or  else  they  form  mixed 
tumors,  such  as  chondro-myxoma,  chondro-lipoma, 
or  chondro-sarcoma.  Cystic  degeneration  may  also 
occur  in  chondromas,  and  by  liquefaction  of  carti- 
laginous tumors  large  cysts  may  form  in  the  long 
bones.  True  chondromas  may  occur  in  the  soft 
parts  from  aberrant  pieces  of  cartilage  in  the  neigh- 
borhood. (Salivary  glands,  neck,  ear,  lungs,  trachea, 
mammary  gland). 

The  mixed  tumors  occurring  in  the  testicles  and 
salivary  glands,  which  develop  cartilaginous  tissue 
through  metaplasia,  are  not  true  chondromas. 

Congenital  chondromas,  and  those  occurring  in 
infancy,  according  to  Virchow,  are  due  to  disturb- 
ances in  the  development  of  bone  during  the  period 
of  growth,  and  arise  from  islands  of  cartilage  left  in 
the  diaphysis.  Rickets  appear  to  play  a  certain  role 
in  this  connection  owing  to  the  irregular  ossification 
of  the  epiphyseal  cartilages.  In  some  cases  these 
appear  to  be  a  hereditary  tendency  to  the  formation 
of  chondromas. 

99 


True  chondromas,  or  enchondromas,  develop  from 
the  periosteum  or  medulla,  most  commonly  in  the 
phalanges  and  metacarpal  or  metatarsal  bones; 
usually  multiple.  Isolated  chondromas  also  occur 
in  the  upper  end  of  the  humerus,  the  lower  end  of 
the  radius,  the  head  of  the  tibia,  the  pelvic  bones 
and  the  scapula,  often  combined  with  cartilaginous 
exostoses  (ossified  ecchondromas  with  a  cartilaginous 
covering) . 

Chondromas  form  slow-growing,  hard,  nodular, 
circumscribed  tumors,  which  may  cause  pressure 
atrophy  of  neighboring  parts  (Fig.  50).  Multiple 
tumors,  especially  in  the  hands,  cause  considerable 
deformity  by  disturbance  of  growth  (shortening  and 
twisting).  Pathological  fracture  may  occur  from 
destruction  of  the  cortex,  in  tumors  growing  from 
the  medullary  cavity. 

The  softer  forms  of  chondroma  must  be  regarded 
as  malignant,  because  they  take  on  an  infiltrating 
growth,  extend  to  the  veins  and  give  rise  to  metas- 
tases.    (Chondro-sarcoma). 

Differential  Diagnosis.  Central  medullary 
chondromas  have  to  be  diagnosed  from  osteomyelitic 
abscesses  and  from  central  sarcoma.  The  former, 
on  X-ray  examination,  show  thickening  of  the  perios- 
teum; the  latter  can  often  only  be  distinguished  by 
operation,  as  the  X-ray  appearances  are  very  similar 
in  chondroma  and  sarcoma  (when  the  chondroma  is 
single).  Large  chondromas  of  the  head  of  the  tibia 
or  upper  end  of  the  humerus  are  easily  recognized  by 
their  nodular  surface  and  hard  consistence. 


Treatment.  Isolated  chondromas  should  always 
be  extirpated,  as  they  may  develop  into  sarcoma. 
Multiple  chondromas  may  be  incised  and  scraped. 
If  rapidly  growing  recurrence  takes  place,  resection 
or  amputation  must  be  performed. 

100 


Fig.  50  shows  a  case  of  multiple  chondromas  of 
the  fingers  in  a  young  man,  which  had  been  present 
since  childhood.  The  nodular  tumors  are  situated 
in  the  phalanges  and  metacarpal  bones,  and  have 
caused  thinning  and  reddening  of  the  skin  by  pres- 
sure. The  X-rays  showed  the  origin  to  be  in  the 
medullary  cavity.  The  tumors  on  the  first,  second 
and  fourth  fingers  were  incised  and  scraped.  The 
little  finger  was  removed  with  its  metacarpal  bone, 
on  account  of  the  multiplicity  of  the  tumors. 


101 


HEMORRHOIDES  ET  FIBROMATA  ANI 

(Jrlemorrhoids  and  Fibromas  of  Anus) 
Plate  XXX^^II,  Fig.  51. 

Among  the  benign  growths  of  the  anus,  hemor- 
rhoids are  the  most  common.  According  to  the 
latest  researches  these  must  be  regarded  not  only  as 
varicose  veins,  but  as  vascular  growths  or  angiomas. 
Hemorrhoids  are  called  external  or  internal,  accord- 
ing as  they  are  situated  in  the  anus  or  rectum. 

External  hemorrhoids  are  due  to  the  formation  of 
new  blood-vessels  and  dilatation  of  the  veins  of  the 
inferior  hemorrhoidal  plexus.  Certain  races  seem 
to  be  predisposed  to  this  affection;  constipation  and 
pelvic  engorgement  may  also  give  rise  to  it. 

These  subcutaneous  hemorrhoids  form  bluish, 
compressible,  nodular,  sessile  growths  covered  by  thin 
skin,  and  situated  around  the  anal  orifice.  There 
is  often  moist  eczema  in  the  neighborhood  (Fig.  51). 
Through  eczema  and  ulceration  the  nodules  may  be 
transformed  into  fibrous  structures  (Fig.  51).  In 
their  inflammatory  state  they  cause  much  itching  and 
pain  with  tenesmus;  while  the  nodules  become  hard 
from  thrombophlebitis,  and  bleed  easily.  Multiple 
internal  hemorrhoids  of  the  lower  part  of  the  rectum 
bleed  easily  without  becoming  inflamed,  and  have 
a  tendency  to  prolapse.  When  they  are  situated 
higher  up  the  rectum,  diagnosis  can  be  made  by 
digital  examination  or  by  the  rectoscope. 

Differential  Diagnosis.  External  hemorrhoids 
may  be  confounded  with  condylomata  acuminata, 
which  are  common  round  the  anus  in  women  suffer- 
ing with  gonorrhea.     These  are  often  as  thick  as  the 

103 


Bockenheimer,  Atlas. 


lab.  XX.XVl 


Fig.  51.     I  laniorrhoides  et  Fibromata  ani. 


Rebman  Company,  Nc«-York. 


finjier,  and  form  similar  cockscomb  growths  on 
account  of  their  papillomatous  structure.  Fibromas 
are  rare,  generally  smaller,  pedunculated  and  solitary. 
Carcinomas,  of  the  papillomatous  type,  are  recog- 
nized by  their  rapid  growth,  inguinal  glandular 
metastases,  early  ulceration  with  hard  borders,  and 
irregular  boundaries.  In  all  cases  of  hemorrhoids 
the  rectum  should  be  digitally  explored  for  carcinoma. 

Treatment.  Laxatives  should  be  given  to  create 
soft  stools,  and  the  anus  should  be  w'ashed  after 
defecation.  During  an  attack,  rest  in  bed  with  the 
pelvis  raised  and  the  introduction  of  pessaries  are 
useful.  Suppurating  hemorrhoids  must  be  incised. 
In  cases  with  frequent  hemorrhages  and  severe  pain, 
a  radical  operation  is  indicated,  either  by  cautery  or 
by  excision  of  the  nodules  with  subsequent  suture. 

Fibromas  and  condylomas  can  be  removed  by 
scissors,  while  carcinoma  requires  more  extensive 
operative  interference. 

Fig.  51  shows  moist  eczema  in  the  region  of  the 
anus.  Round  the  anus  are  yellowish,  nodular,  hem- 
orrhoidal growths,  which  have  a  resemblance  to 
fibromas  on  account  of  inflammatory  changes  and 
ulceration.  In  one  place  is  a  bluish,  glistening  nod- 
ule covered  by  thin  skin.  The  growths  were  removed 
by  the  thermo-cautery. 


103 


Lipoma 

FIBROLIPOMA  PENDULUM  SUBCUTANEUM 

{Pendulous  Fibrolipoma) 
Plate  XXXIX,  Fig.  .52. 

LIPOMA  DIFFUSUM  SUBCUTANEUM 

(Diffuse  Subcutaneous  Lipoma) 
Plate  XL.  Fig.  5.'?. 

LIPOMATA  SYMMETRICA  SUBCUTANEA 

{Symmetrical  Subcutaneous  Lipomata) 
Plate  XLl/Fig.  5i. 

Lipomas  are  tumors  formed  of  fatty  tissue,  and 
have,  therefore,  the  yellowish-white  color,  soft  con- 
sistence, and  lobular  structure  of  fatty  tissue.  The 
individual  fat  lobules  are  separated  by  more  or  less 
strongly  developed  connective-tissue  septa,  and  the 
whole  tumor  is  demarcated  from  the  surrounding 
tissues  by  a  thin  capsule.  Lipomas  are  of  soft  con- 
sistence, often  with  pseudo-fluctuation;  in  rare  cases 
harder,  from  the  development  of  more  connective 
tissue.  They  are  slow-growing  globular  tumors, 
which  sometimes  attain  an  enormous  size,  and  are 
usually  supplied  by  a  single  vessel  at  the  base  of  the 
tumor.  At  the  base  of  the  larger  tumors  the  skin  is 
generally  drawn  out  into  a  pedicle,  and  is  often 
cedematous.  Lipomas  are  essentially  benign  tumors; 
they  do  not  recur  or  give  rise  to  metastases,  nor  do 
they  become  transformed  into  malignant  tumors. 
Besides  the  fatty  tissue,  other  tissues  may  be 
developed  (fibro-lipoma,  myxo-lipoma,  angio-lipoma, 
chondro-lipoma).  Cystic  degeneration  may  give  rise 
to  so-called  oil-cysts  in  the  interior  of  lipomas. 

Multiple,  usually  symmetrical  lipomas,  are  due 
to    disturbances    in    development.      They    may   be 

104 


Bockenheimer,  Atlas. 


Tab.  .\.\.\i.\. 


Fig.  52.     Fibrolipoma  subcutancum  pendulum. 


Rebman  Company,  Nc«--York. 


connected  with  nerves  (multiple  lipomas  are  often 
painful)  or  with  lymphatic  glands,  which  have  been 
found  in  multiple  lipomas.  Congenital  lipoma  is 
found  especially  in  spina  bifida,  which  arises  as  a 
myelo-cystocele,  and  usually  as  a  myxolipoma  (Fig. 
144).  That  lipomas  are  true  tumors  is  shown  by 
their  persistence  in  severe  emaciation.  Long-con- 
tinued pressure  on  a  lipoma  may  cause  suppuration 
of  the  fatty  tumor  through  ulceration  of  the  skin. 

That  chronic  irritation  plays  a  part  in  the  develop- 
ment of  lipomas  is  shown  by  the  occurrence  of  these 
tumors  on  the  backs  of  carriers,  and  on  the  foreheads 
of  persons  who  wear  hard  hats.  Middle-aged  women 
are  especially  affected  by  these  tumors,  which  may 
grow  considerably  during  pregnancy. 

Lipomas  are  most  often  found  in  the  subcutaneous 
tissue  (Figs.  52,  53  and  54),  where  they  appear  as 
soft,  encapsuled  tumors  with  a  lobulated  surface, 
covered  by  non-adherent  skin.  The  skin  over  the 
tumor  becomes  dimpled  when  pinched  up,  owing  to 
its  connection  with  the  tumor  by  connective  tissue 
(Fig.  53) .  The  seats  of  predilection  for  subcutaneous 
lipomas  are  the  back,  nape  of  the  neck,  axilla,  shoul- 
der, upper  arm,  thigh,  buttocks  and  scrotum. 

Sub-fascial  lipomas  are  very  rare.  They  may 
occur  under  the  fascia  of  the  forehead  (where  they 
may  be  mistaken  for  dermoids)  and  under  the  palmar 
fascia.  Intermuscular  lipomas  occur  behind  the  pec- 
toralis  major  and  in  the  tongue.  In  the  knee  joint 
arborescent  lipoma  occurs,  which  has  the  typical 
structure  of  fatty  tissue.  Lipomas  may  also  arise 
from  the  sub-mucous  and  sub-serous  tissue  (gut  and 
larynx) ;  sub-peritoneal  lipomas  may  give  rise  to 
hernia  through  the  linea  alba.  Sub-serous  lipomas 
also  sometimes  appear  in  the  inguinal  and  femoral 
canals;  in  the  omentum  and  mesentery;  in  the 
retroperitoneal  tissue,  and  in  the  glandular  organs 
(breast  and  kidney). 

All  lipomas,  especially  sub-cutaneous,  sub-fascial 

105 


and  intermuscular,  have  a  tendency  to  send  processes 
into  the  surrounding  parts. 

Differential  Diagnosis.  Superficial  lipomas  are 
distinguished  from  fibiomas,  lymphomas,  dermoids, 
sebaceous  cysts,  hygromas  and  other  tumors  by  their 
lobular  surface  and  the  puckering  of  the  skin.  When 
they  cannot  be  palpated,  lipomas  cannot  always  be 
distinguished  from  other  tumors. 

Treatment.  Incision  through  the  skin  and  re- 
moval of  the  tumor  with  its  processes. 

Diffuse  lipomas,  which  consist  in  an  infiltration  of 
the  sub-cutaneous  tissue  with  fatty  masses  without 
any  capsule,  are  not  to  be  regarded  as  true  tumors 
(lipomatosis  of  Billroth).  In  the  neck  they  may  be 
dangerous  from  pressure  on  the  larynx,  so  that 
removal  is  necessary,  although  this  must  generally 
be  incomplete.  The  fatty  masses  may  also  be  made 
to  shrink  by  the  injection  of  alcohol  and  ether. 

Fig.  52  shows  a  pendulous  fibro-lipoma  in  a  middle- 
aged  woman.  The  skin  is  somewhat  reddened,  but 
non-adherent.  The  surface  of  the  tumor  is  smooth, 
the  consistence  moderately  hard.  The  tumor  is 
movable  over  the  fascia.  The  base  of  the  tumor  is 
broad,  on  account  of  its  small  size.  The  tumor  was 
removed  by  an  oval  incision  and  suture. 

Fig.  53  shows  a  sub-cutaneous  lipoma  the  size  of 
the  fist  in  a  common  situation  in  a  middle-aged 
woman.  The  puckering  of  the  skin  is  clearly  seen. 
These  puckerings  (white  spots  in  the  figure)  are  also 
found  in  the  breast,  and  are  due  to  processes  of  the 
lipoma  extending  into  the  breast.  The  tumor  with 
its  processes  was  extirpated. 

Fig.  54  shows  symmetrical  lipomas  in  the  region 
of  both  parotids,  in  the  upper  eyelids,  and  in  various 
parts  of  the  neck  (both  sides  of  sub-maxillary  region 
and  in  sub-lingual  region)  in  an  old  man.    The  pain- 

106 


Bockenlieimer,  Atlas. 


Fig.  53.    Lipoma  diffusum  siibcutanciim. 


Rebman  Company,  New-Vork. 


Bockenheimer,  Atlas. 


Tab.  XLI. 


Fig.  54.     Liponiata  subcutanea  symmetrica. 


Rcbman  Company,  N'cw-York. 


less  tumors  had  not  increased  in  size  for  some  years. 
Their  lobular  surface  and  their  consistence  distin- 
guish these  solid  tumors  from  symmetrical  cystic 
formations  in  the  salivary  glands,  which  cause  simi- 
lar swellings  in  the  face  and  neck.  The  disease  is 
distinguished  from  lipomatosis  by  consisting  of  mul- 
tiple, separate,  encapsuled  tumors.  There  were  no 
other  lipomas  in  other  parts  (in  distinction  to  cases  in 
which  lipomas  occur  over  the  whole  body).  The 
tumors  were  removed  at  several  sittings. 


107 


GRANULATIONES  ET  TRANSPLANTATIONES 

{Graiudations  and  Skin  Grafting) 
Plate  XLII,  Fig.  55. 

This  plate  shows  a  granulating  wound  of  the  right 
breast,  left  after  extirpation  of  the  mammary  gland. 
After  extirpation  of  the  breast,  an  attempt  should  be 
made  to  close  the  wound  by  sutures,  but  these  should 
not  be  tied  too  tightly,  especially  in  the  center  of  the 
wound,  as  they  are  liable  to  tear  through  the  tissues 
and  cause  sloughing.  The  figure  shows  the  reddish- 
brown  holes  of  the  sutures,  which  have  led  to  partial 
closure  of  the  wound  in  the  center.  The  remainder 
of  the  wound  can  be  left  to  heal  by  granulation,  and 
Thiersch's  grafts  may  be  applied.  The  surface  of 
the  wound  must  first  be  cleansed,  and  the  granula- 
tions must  be  bright  red  and  exuberant  (Fig.  55). 
Moist  dressings  of  3  per  cent,  boric  acid  lotion  and 
2  per  cent,  acetic  alum  are  then  applied.  The  figure 
shows  three  epidermic  grafts  which  have  become 
attached  to  the  red  granulations.  On  the  axillary 
side  the  granulations  are  still  yellowish,  and  are  not 
yet  ready  for  grafting. 

When  the  whole  surface  of  the  wound  is  covered 
with  red,  exuberant  granulations,  these  are  removed 
with  a  scalpel,  and  the  bleeding  surface  compressed 
with  hot  compresses  soaked  in  saline  solution;  the 
largest  possible  epidermic  grafts  are  then  applied 
and  covered  with  iodoform  gauze  and  plaster.  The 
figure  also  shows  the  appearance  of  such  granula- 
tions as  they  occur  in  the  course  of  the  undisturbed 
wound. 


108 


Bockenheimer,  Atlas. 


Fig.  55.    Oranulationes  et  Transplantationes. 


Rebman  Company,  New-York. 


Bockenheimer,  Atlas. 


Tab.  XL 


Fig.  56.     Fistula  ex  corpore  alieno. 


Pt^l^rn^n    f'nynn^nv      W*»of_Vr\rlf 


FISTULA   EX   CORPORE   ALIENO  {Fistula  from  foreign  bodies) 
Plate  XLIII,  Fig.  56. 

As  the  result  of  incision  of  a  paranephritic  abscess, 
a  fistula  has  remained,  which,  in  spite  of  drainage, 
tamponage  and  repeated  scraping,  has  not  healed. 
The  surrounding  skin  is  inflamed  and  oedematous. 
The  granulations  at  the  opening  of  the  fistula  are 
unhealthy,  dirty-brown  and  purulent.  Shreds  of 
tissue  with  a  fetid  odor  are  discharged  from  the  fistula. 

Such  an  appearance  of  the  fistula  and  its  sur- 
roundings is  typical  of  all  cases  where,  either  the 
external  opening  is  too  small,  so  that  an  abscess  in 
connection  with  it  is  not  sufficiently  drained,  or 
where  necrosed  pieces  of  tissue  in  the  deeper  parts 
are  cast  off  and  act  as  foreign  bodies  {e.g.  bony  seques- 
tra in  coxitis,  etc.  (Figs.  95  and  96).  Similar  fistu- 
las, with  an  offensive  sanious  discharge,  sometimes 
result  from  tampons,  drains,  or  instruments  being  left 
behind  after  operations. 

In  pyogenic  lesions  which  have  been  insufficiently 
incised,  the  presence  of  unhealthy,  purulent  granula- 
tions shows  that  the  pus  has  not  a  free  outlet,  or  that 
the  lesion  is  extending.  When  a  local  pyogenic 
lesion  gives  rise  to  general  pysemia  the  wound  shows 
similar  changes,  but  the  granulations  besides  having 
a  dirty-yellow  appearance  are  quite  dry. 

Treatment  must  be  directed  to  the  cause  of  the 
fistula.  The  latter  should  be  laid  open  freely,  and 
foreign  bodies  or  pieces  of  necrosed  bone  removed, 
after  which  healing  will  take  place. 

In  the  case  represented  in  Fig.  56,  the  kidney  was 
found  to  be  almost  completely  destroyed  by  suppura- 
tion. Healing  quickly  took  place  after  removal  of 
the  kidney. 

109 


FISTULA  COLLI  MEDIANA  (Median  Fistula  of  the  Neck) 
Plate  XLIV,  Fig.  57. 

Median  fistula  of  the  neck  is  due  to  the  persistence 
of  the  thyro-glossal  duct,  which  in  embryonic  life 
leads  from  the  foramen  caecum  at  the  back  of  the 
tongue  to  the  middle  lobe  of  the  thyroid  gland. 
Lateral  fistulse  of  the  neck  are  due  to  imperfect 
closure  of  the  second  branchial  cleft. 

The  lateral  fistulse  may  also  open  in  the  middle 
line,  so  that  their  true  nature  can  only  be  made  out 
by  tracing  their  course.  This  can  be  done  by  pal- 
pation, by  the  passage  of  a  probe,  or  by  injection  of 
milk.  The  lateral  fistulee  of  the  neck  deviate  from 
the  middle  line,  perforate  the  superficial  fascia  of 
the  neck  parallel  to  the  sterno-mastoid  muscle 
behind  the  greater  cornu  of  the  hyoid  bone,  and  open 
into  the  side  of  the  pharynx  near  the  tonsil,  while 
the  course  of  median  fistulse  remains  in  the  middle 
line,  passing  behind  or  through  the  hyoid  bone  to 
the  base  of  the  tongue,  and  opening  at  the  foramen 
cfecum.  If  the  internal  opening  of  a  fistula  is  open 
and  the  outer  opening  closed,  it  is  an  internal  incom- 
plete fistula;  if  the  outer  opening  is  open  but  the 
inner  one  closed,  it  is  an  external  incomplete  fistula. 
If  both  openings  are  closed,  branchial  cysts  are 
formed  in  the  case  of  lateral  fistulae,  and  median 
cysts  (from  the  thyro-glossal  duct)  in  the  case  of 
median  fistula. 

Median  fistula  of  the  neck  (Fig.  57),  although  of 
congenital  origin,  is  not  usually  noticed  for  several 
years,  for  it  is  formed  by  an  internal  incomplete 
fistula  which  gradually  perforates  the  skin  of  the 
neck.     The  fistula  generally  opens  in  the  middle  line 

110 


Bockenheimer,  Atlas. 


Tab.  XI  IV. 


M.>.Tf_V/M-^ 


between  the  hyoid  bone  and  the  sternum,  and  is 
characterized  by  certain  signs  which  are  also  found 
in  lateral  fistula  which  opens  on  the  inner  border  of 
the  sterno-mastoid  muscle.  The  latter  are  more 
often  congenital.  In  both  cases  there  is  a  small 
button-shaped  opening,  which  is  sometimes  glued 
together,  sometimes  discharges  a  drop  of  clear  whit- 
ish fluid.  There  are  regularly  arranged  radiating 
cicatrices  round  the  fistula.  If  there  is  much  secretion 
the  skin  may  be  eczematous.  On  palpation,  a  hard 
cord,  as  thick  as  a  quill  pen,  can  be  felt  passing 
towards  the  middle  line  or  laterally,  according  to  the 
nature  of  the  fistula.  Above  the  hyoid  bone  the  cord 
cannot  be  felt.  The  direction  of  the  fistula  is  shown 
better  by  probing;  the  probe  can  hardly  ever  be 
passed  beyond  the  hyoid  bone.  However,  if  milk  is 
injected  it  can  be  seen  to  flow  out  near  the  tonsil  in 
the  case  of  lateral  fistula,  and  at  the  foramen  caecum 
at  the  base  of  the  tongue  in  the  case  of  median  fistula. 
Narrow  fistulas  cause  little  trouble  to  the  patient, 
but  in  wide,  lateral  fistulas  accumulation  of  food 
may  cause  inflammation  and  abscess.  Carcinoma 
may  arise  from  fistulas  and  cysts  of  the  neck;  it  is 
called  branchiogenous,  as  it  is  derived  from  the 
epithelium  of  the  branchial  clefts. 

Differential  Diagnosis.  Fistulas  arising  from 
tuberculous  or  inflammatory  processes  differ  both  in 
their  external  appearance  and  in  the  course  of  the 
fistulous  track.  In  doubtful  cases  microscopic  exam- 
ination may  be  made. 

Treatment.  Injections  with  the  object  of  causing 
obliteration  of  the  fistula  are  useless.  The  only 
rational  treatment  is  total  extirpation  of  the  fistula 
through  a  long  incision,  bearing  in  mind  the  anatomy 
of  the  parts.  In  lateral  fistula  it  is  best  to  remove 
the  internal  orifice  together  with  the  tonsil.  In 
median  fistula,  it  is  sometimes  necessary  to  remove 

111 


the  middle  part  of  the  hyoid  bone,  in  order  to  follow 
the  track  to  the  foramen  csecum.  Recurrence  is  fre- 
quent if  the  smallest  part  of  the  fistulous  track  is  left 
behind.  Microscopic  examination  of  both  median 
and  lateral  fistulas  shows  squamous  epithelium  in 
distal  sections,  cylindrical  epithelium  in  proximal 
sections.  The  presence  of  lymphoid  tissue  in  the 
wall  of  the  fistula  is  characteristic. 

Fig.  57  shows  a  median  fistula  of  the  neck  in  a  girl 
aged  nineteen.  The  fistula  first  appeared  at  the  age 
of  fifteen,  and  was  treated  by  injection  and  incision, 
without  any  result.  A  drop  of  secretion  is  seen  at 
the  orifice  of  the  fistula.  Radiating  cicatrices  are 
also  visible.  The  fistulous  track  could  be  felt  as  a 
cord  as  far  as  the  hyoid  bone,  but  its  further  course 
could  not  be  made  out  by  injection  of  fluid.  The 
foramen  csecum  was  deep.  After  an  incision  round 
the  opening  of  the  fistula  together  with  the  scar  tissue, 
the  track  was  dissected  out.  The  center  of  the  hyoid 
bone,  through  which  the  track  penetrated,  was 
removed,  so  as  to  continue  the  extirpation  to  the  base 
of  the  tongue.  Microscopic  examination  showed 
squamous  epithelium  in  the  lower  part  of  the  fistula 
and  ciliated,  cylindrical  epithelium  in  the  upper  part. 


112 


Bockenheimer.  Atlas. 


Tab.  XLV. 


n 

C3 


•a 


in 
to 


5 

'u 

> 

"55 
o 


T3 


lis: 


00 

in 


bJ3 


Keloid 

Plate  XLV. 

KELOID   POST   VACCmATIONEM   {Keloid  after  Vaccination) 

Yi'r.   5S. 

KELOID  POST  LAPAROTOMIAM  (Keloid  after  Laparotomij) 

Fig.  59. 

This  disease,  the  etiology  of  which  is  still  obscure, 
consists  in  the  formation  of  homogenous,  fibrous 
tumors  in  the  skin  which  are  formed  of  hypertrophic 
scar  tissue  with  thickened  blood-vessels.  The  chief 
part  of  the  growth  consists  of  dense,  hyaline,  often 
interlacing  bundles  of  connective  tissue,  while  cells 
and  elastic  fibers  are  few  in  number.  Only  a  few 
cases  can  be  spoken  of  as  true  tumors. 

The  papillary  bodies  are  unchanged,  but  lying 
under  them  are  nodules  or  lamella%  more  or  less  rich 
in  cells  (keloid-nodular  cancer).  In  the  lamellar 
form  (Fig.  58)  there  are  radial  processes  at  the  periph- 
ery which  are  often  prolonged  as  fine  processes  into 
the  skin.  The  keloid  presents  itself  as  a  tumor  of 
hard  consistence,  with  a  smooth,  glistening  surface, 
of  reddish  (Fig.  58)  or  yellowish-white  color  (Fig. 
59),  situated  in  the  skin  and  movable  over  subjacent 
structures.  Keloids  are  painless,  of  slow  growth, 
and  then  remain  the  same  size  for  some  time.  They 
are  common  in  young  women.  Pain  and  irritation 
may  be  caused  by  pressure  on  the  tumors,  especially 
when  they  are  of  large  size,  or  situated  in  places 
exposed  to  frequent  pressure  or  contact. 

It  is  now  believed  that  keloids  occur  exclusively 
after  injuries  (operations,  vaccination,  scars  caused 
by  flagellation,  burns,  chronic  ulcers,  etc.),  and  that 

113 


there  is  a  local  or  general  disposition  to  keloid  for- 
mation in  the  individual  affected.  It  has  not  been 
proved  that  infected  wounds  are  more  liable  to  form 
keloids.  Certain  parts  of  the  body  are  more  affected 
than  others — the  shoulders,  face,  abdomen  and  exter- 
nal ears — while  the  extremities  are  seldom  affected. 
Dark  races  have  a  special  tendency  to  keloid  forma- 
tion. 

Glandular  enlargement  and  metastases  are  not 
observed,  but  large  keloids  may  ulcerate,  and  cancer 
may  develop  from  the  ulcers. 

Differential  Diagnosis.  Hypertrophic  scars 
may  be  mistaken  for  incompletely  developed  keloids, 
but  the  former  are  usually  very  sensitive,  are  not  so 
extensive  as  keloid,  occur  especially  after  infected 
wounds,  and  nearly  always  undergo  partial  resolution 
after  some  years. 

Treatment.  Operation  is  to  be  avoided,  as  recur- 
rence nearly  always  takes  place  after  extirpation,  with 
or  without  a  plastic  operation,  after  cauterization 
and  scraping,  and  the  recurrent  growth  is  often  more 
extensive  than  the  original.  Electrolysis,  or  injection 
of  a  10  per  cent,  solution  of  thiosinamin  sometimes 
cause  improvement. 

Fig.  58  shows  a  keloid  in  a  young  girl,  which  arose 
from  a  vaccination  scar  and  recurred  extensively 
after  extirpation.  An  extensive  flat  growth  is  seen 
with  radiating  processes ;  also  smaller  nodular  growths 
in  the  neighborhood. 

Fig.  59  shows  an  extensive  nodular  keloid  in  a 
woman  of  twenty,  which  developed  in  the  scar  of  a 
laparotomy.  At  each  suture  hole  a  nodule  has  devel- 
oped. At  the  lower  part  are  hard,  cauliflower 
nodules,  freely  movable  and  covered  by  epidermis. 
Injection  of  thiosinamin  solution  into  the  nodules 
caused  partial  disintegration,  but  later  on  further 
recurrence  took  place  in  the  parts  treated. 

114 


Bocketilieinier,  Atlas. 


Tab.  XLVl 


h"ig.  bO.    Coiitractura  aponeurosis  pahnaris  (Uupuytreii). 


Rcbman  Company,  Ne^x■-York. 


CONTRACTURA  APONEUROSIS  PALMARIS   (Dupuylren) 

{Dupmjtren  s  Contrartttre  oj  Palmar  aponeurosis) 

Plate  XLVI,  Fig.  60. 

The  palmar  aponeurosis,  the  continuation  of  the 
palmaris  longus  muscle,  which  spreads  over  the  palm 
and  sends  processes  to  the  proximal  phalanges  of  all 
the  fingers,  and  is  also  connected  with  the  skin,  may 
be  affected  by  chronic  inflammation  leading  to  con- 
nective-tissue formation  and  subsequent  contracture. 
Hard  nodules  develop  in  the  aponeurosis  and  skin, 
which  finally  become  hard  cords.  These  cord-like 
thickenings  occur  not  only  in  the  palm,  but  even 
more  commonly  in  the  processes  of  the  aponeurosis 
connected  with  the  second,  third,  fourth  and  fifth 
fingers.  Contraction  of  these  cords,  which  at  the 
base  of  the  phalanges  are  connected  with  the  tendon 
sheaths,  gives  rise  to  an  abnormal  position  of  the 
fingers,  called  Dupmjtren' s  contracture.  This  term 
signifies  limitation  of  movement  in  the  joints  which 
may  be  of  arthrogenous,  neurogenous,  myogenous, 
tendogenous,  or  dermatogenous  origin. 

The  fourth  and  fifth  fingers  are  those  most  often 
affected  by  Dupuytrens  contracture,  the  second  and 
third  less  often,  and  the  thumb  least  often.  The  dis- 
ease usually  begins  in  the  fourth  or  fifth  finger  and 
may  spread  to  all  the  others.  It  is  often  symmetrical, 
affecting  both  hands  at  the  same  time  and  to  the 
same  extent.  Before  the  commencement  of  contrac- 
tion, nodular,  fibrous  thickenings  can  be  felt  in  the 
skin,  later  on  fibrous  cords  are  formed,  by  which 
first  the  proximal  phalanges,  later  on  the  middle 
phalanges  become  fixed  in  a  position  of  flexion, 
while  the  terminal  phalanges  maintain  their  power 

115 


of  extension.  After  some  years  the  contraction 
becomes  so  severe  that  the  finger  is  completely 
doubled  on  itself  into  the  palm,  and  cannot  be 
extended.  There  is  generally  some  power  of  exten- 
sion of  the  middle  and  terminal  phalanges,  but  as 
this  is  painful  it  is  avoided  by  the  patient. 

The  affection  occurs  exclusively  in  men  and  was 
hence  attributed  to  traumatic  influence  by  Diqmy- 
tren.  At  any  rate  the  affection  is  often  found  in 
people  in  whom  the  palm  of  the  hand  is  exposed  to 
continued  pressure  (in  post-office  clerks,  as  the  result 
of  stamping,  persons  who  carry  guns,  carpenters,  etc.). 
Some  authorities  attach  little  importance  to  the  action 
of  trauma,  and  the  disease  often  occurs  in  gouty 
people.  As  the  contraction  is  often  symmetrical  and 
equally  developed  on  both  sides,  a  central  nervous 
origin  is  possible. 

Differential  Diagnosis.  Dupui/tren's  contrac- 
ture differs  from  contracture  due  to  cutaneous  scars, 
by  the  skin  over  it  being  intact.  Fibromas  of  ten- 
dons or  tendon  sheaths  (Fig.  49)  form  rounded 
swellings.  In  occupational  contracture  of  the  fingers, 
there  are  no  hard  cords  in  the  palm,  and  the  pha- 
langes of  all  the  fingers  are  usually  equally  flexed. 
In  arthrogenous  contracture  the  joints  are  obviously 
affected. 


Treatment.  Mechanical  treatment  and  massage 
are  incapable  of  arresting  the  progress  of  the  disease. 
In  severe  cases  operation  is  indicated,  according  to 
Kocher  excision  of  the  affected  parts  of  the  palmar 
aponeurosis.  Those  parts  of  the  skin  which  show 
fibrous  changes  should  also  be  removed,  and  the 
wound  repaired  by  skin  flaps.  Massage,  commenced 
soon  after  the  operation,  may  give  good  functional 
results.  Treatment  by  injection  of  thiosinamin  is 
at  present  inconclusive. 

116 


Fig.  60  shows  a  case  of  Dupuytreri's  contracture  of 
the  fourth  and  fifth  fingers  in  a  man  of  fifty.  The 
httle  finger  is  considerably  contracted,  and  only  the 
last  phalanx  can  be  freely  extended.  The  fourth 
finger  shows  contracture  of  the  first  phalanx  and 
commencing  contracture  of  the  second.  Contrac- 
ture is  also  beginning  in  the  third  finger.  The 
afl"ection  was  of  several  years  duration,  and  caused 
so  little  trouble  that  operation  was  refused. 


117 


CONTRACTURA  POST  PANARITIUM  TENDINOSUM 

{Contrarture  offer  Tendon  Sheath  Suppuration) 
Plate  XLMI,  Fig.  61. 

Cutaneous  contractures  affect  chiefly  the  flexor 
surface  of  the  fingers  and  palm,  and  originate  in  the 
scars  of  operations,  wounds,  burns  and  inflamma- 
tions. Tendon  contracture  is  often  associated  with 
cutaneous  contracture,  especially  when  there  is  sup- 
puration within  the  tendon-sheaths,  so  that  the  finger 
becomes  stiff  and  fixed  firmly  in  a  contracted  posi- 
tion. Fig.  61  shows  a  hard,  slightly  movable  sear, 
extending  from  the  flexor  surface  of  the  last  joint  of 
the  middle  finger  to  the  center  of  the  palm,  arising 
from  an  incision  for  suppuration  of  the  tendon 
sheath  (cf.  Fig.  93).  The  nature  of  the  lesion,  and 
the  fact  that  there  is  no  power  of  motion  in  the 
finger,  shows  that  the  flexor  tendon  is  destroyed. 
Hence,  the  contracture  is  both  dermatogenous  and 
tendogenous,  i.e.  caused  by  contraction  of  both  skin 
and  tendon. 

In  cases  where  the  tendon  is  partly  destroyed,  or 
very  firmly  connected  with  the  hypertrophic  cuta- 
neous scar,  operative  treatment  is  not  successful. 
After  excision  of  the  scar,  contracture  occurs  in  the 
new  scar,  in  spite  of  extension  of  the  finger,  length- 
ening of  the  tendon,  transplantation  of  tendon  or 
catgut,  or  plastic  operations.  If  the  patient  is  inca- 
pacitated from  work  by  the  contracture,  exarticula- 
tion  of  the  fingers  gives  the  most  useful  result,  the 
use  of  the  thumb  being  cultivated  to  take  their  place. 

In  cases  of  tendon-sheath  suppuration,  contracture 
may  be  prevented  by  making  small  lateral  incisions 
in  the  finger.     If  the  tendon  is  not  destroyed  by  sup- 

118 


Hockenlieinier,  Atlas. 


Tab.  XIAII. 


/: 


o 


~r. 


Rebman  Company,  Ne^»  -\'ork. 


puration,  the  skin  contracture  can  then  be  prevented 
by  early,  active  and  passive  movements,  massage, 
baths,  etc. 

In  cases  of  contracture  limited  to  the  skin,  such  as 
those  after  cuts  and  burns,  keloid  scars,  superficial 
suppuration,  etc.,  the  prognosis  is  much  better.  The 
mobility  of  the  scar  over  the  deeper  structures  and 
the  power  of  moving  the  individual  phalanges,  show 
that  the  tendon  is  not  implicated.  Excision  of  the 
scar,  extension  of  the  finger,  in  some  cases  lengthen- 
ing of  the  tendon,  and  repair  of  the  wound  by  skin 
flaps,  in  these  cases  restores  the  function  of  the 
finger.  In  young  persons  good  results  can  be 
obtained  by  orthopedic  treatment,  when  the  scar  is 
not  very  extensive,  nor  hypertrophic,  nor  of  too  long 
standing. 


119 


HAEMARTHROS  COMPRESSIO  N.  ULNARIS 

{Hemarthrogis  Compress-ion  of  Ulnar  Nerve,  Neurogenous  CordToclure) 
Plate  XLVII,  Fig.  6'2. 

Neurogenous  contractures  affect  the  hand  and 
fingers,  and  result  from  injuries  to  the  radial,  ulnar 
and  median  nerves.  They  may  be  of  peripheral  or 
central  nervous  origin.  In  contractures  of  central 
origin,  especially  in  the  paralytic  contractures  due  to 
anterior  poliomyelitis,  nerve  transplantation,  and 
shortening  or  transplantation  of  tendons  may  be 
performed.  Treatment  by  massage,  electricity  and 
orthopedic  apparatus  is  also  useful.  In  contractures 
due  to  lesions  of  the  peripheral  nerves  (division  of 
nerve;  pressure  from  badly  united  fracture,  effusion 
of  blood,  or  tumors  on  the  nerve),  exposure  of  the 
nerve,  with  excision  of  the  injured  part  and  subse- 
quent suture  is  sometimes  successful. 

Fig.  62  shows  a  reflex  contracture  resulting  from  a 
blow  on  the  ulnar  side  of  the  wrist  joint,  causing 
effusion  of  blood  into  the  joint  (hemarthrosis)  which 
pressed  on  the  ulnar  nerve.  Compression  of  the 
ulnar  nerve  by  the  joint  effusion  gave  rise  to  "claw 
hand" — by  hyperextension  of  the  proximal  pha- 
langes and  flexion  of  the  second  and  third  phalanges. 
There  was  slight  swelling  on  the  back  of  the  wrist 
joint,  chiefly  on  the  ulnar  side.  Fluctuation  was 
present.  The  sign  of  "snowball  crunching"  indi- 
cated the  presence  of  blood  clots,  and  therefore  of 
hemarthrosis.  The  movements  of  the  joints  were 
limited  and  very  painful.  The  joint  was  in  a  posi- 
tion of  slight  flexion,  but  could  be  easily  extended. 

130 


The  hand  was  fixed  on  a  splint  and  recover^'  took 
place  after  absorption  of  the  blood. 

The  diagnosis  between  the  different  kinds  of  neu- 
rogenous contractures,  and  between  these  and  other 
contractures  often  requires  an  examination  of  the 
whole  nervous  system.  Hysterical  contracture  of  the 
knee  and  hip  joints,  which  is  common  in  children, 
disappears  under  an  anaesthetic. 


121 


CONTRACTURA  ISCHAEBnCA  BRACHH 

(Ischaemic  contracture  of  the  arm) 
Plate  XLVIII.  Fig.  03. 

Myogenous  contractures  occur  most  commonly  in 
the  upper  extremity,  as  a  result  of  injuries  and  sup- 
puration in  the  muscles,  which  cause  shortening  of 
the  muscles  and  their  tendons.  They  also  occur  in 
diseases  of  the  nervous  system,  both  peripheral  and 
central.  Contracture  also  results  from  too  long 
immobilization  of  a  limb,  the  over-action  of  the 
flexor  muscles  causing  flexion  contracture  of  the  arm, 
wrist  and  fingers. 

These  contractures  are  most  marked  in  ischaemic 
muscular  contracture  (Volkmann),  which  is  gener- 
ally observed  in  the  upper  extremity  of  young  per- 
sons. The  causes  of  this  condition  include  fractures 
{e.g.  supra-condyloid  fracture  of  the  humerus),  rup- 
ture of  the  intima  of  blood-vessels,  obstruction  of 
large  vessels,  exposure  to  cold,  prolonged  action  of 
Esmarch's  elastic  bandage,  and  constriction  by 
plaster  of  Paris  bandages.  A  constricting  bandage 
is  sufficient  to  cause  ischaemia  in  the  arm. 

The  greater  frequency  of  contracture  in  the  upper 
extremity  is  explained  by  the  fact  that,  owing  to 
there  being  less  muscle  in  the  arm  than  in  the  thigh, 
the  vessels  are  more  easily  compressed.  Out  of 
thirty-five  cases  collected  by  Bardenheuer,  there  was 
only  one  affecting  the  leg.  The  greater  frequency 
of  ischaemic  contracture  in  young  individuals  is  due 
to  the  greater  compressibility  of  their  muscles  and 
vessels.  In  older  persons  great  pressure  on  the  ves- 
sels is  liable  to  cause  gangrene  owing  to  arterio- 
sclerosis; even  slighter  pressure  may  give  rise  to 
obliterative  thrombosis  and  consequent  gangrene. 

122 


Bockenheimer,  Atlas. 


Tab.  XLVIIF. 


o 


U 


It  must  be  borne  in  mind  that  muscular  tissue  is 
more  affected  than  skin  and  bone  even  by  short  inter- 
ruption of  the  blood  supply,  because  the  compressed 
vessels  are  terminal  branches. 

The  affection  begins  in  the  peripheral  parts  of  the 
extremities.  The  fingers  become  blue,  swollen,  cold 
and  moist,  painful  on  movement,  which  can  only  be 
done  passively,  and  flexed.  In  cases  where  the 
affection  is  due  to  tight  bandaging,  after  early 
removal  of  the  bandage  the  skin  appears  white, 
while  the  muscles  feel  as  hard  as  a  board  and  immo- 
bile, but  recover  after  proper  treatment.  If  the  con- 
stricting bandage  is  allowed  to  remain,  in  a  few 
hours  the  muscles  become  bloodless  and  undergo 
degeneration,  having  a  waxy-yellow  appearance  as 
in  tj'phus.  As  the  result  of  extensive  muscular  atro- 
phy, shrinking  of  the  muscles  takes  place  and  causes 
contracture.  The  patients  suffer  severe  pain  for  a 
long  time  after  removal  of  the  bandage.  The  skin 
of  the  fingers  gradually  becomes  yellowish-white  like 
parchment.  The  swelling  of  the  fingers  is  followed 
by  shrinking.  First  of  all  the  fingers,  then  the  meta- 
carpal bones,  and  finally  the  wrist  become  fixed  in  a 
position  of  flexion.  The  fingers  are  eventually  so 
strongly  flexed  that  the  hand  becomes  useless.  The 
movements  of  the  wrist  are  also  very  limited,  and 
the  muscles  of  the  forearm  become  atrophied  and 
are  covered  by  pale  skin.  Sensory  disorders  may 
occur  from  pressure  of  the  shrunken  muscles  on  the 
nerves,  and  in  some  cases  ischaemic  muscular  con- 
tracture is  followed  by  ischaemic  paralysis. 

The  clinical  appearance  of  myogenous  contrac- 
ture, especially  ischaemic  muscular  contracture,  is 
so  characteristic  that  it  can  hardly  be  mistaken  for 
other  forms  of  contracture. 

Treatment.  Myogenous  contracture,  when  not 
of  too  long  standing,  may  be  improved  by  massage, 
electricity,    baths    and    hot-air    treatment.     Prophy- 

123 


lactic  treatment  consists  in  avoiding  the  use  of  too 
tight  bandages,  and  too  long  fixation  of  the  limb. 

In  the  application  of  plaster  bandages  to  fractures 
of  the  upper  extremity  certain  definite  rules  must  be 
observed.  The  limb  must  be  well  wrapped  in  cotton 
wool,  which  must  be  loose  at  the  extremity,  and  the 
limb  should  be  suspended  to  assist  the  venous  circu- 
lation. The  bandage  must  be  removed  if  the  fingers 
become  blue,  swollen  or  painful.  Patients  with 
plaster  of  Paris  bandaging  must  be  kept  under  con- 
tinuous observation.  The  bandage  should  always 
be  changed  on  the  eighth  day,  when  light  massage  of 
the  muscles  and  movement  of  the  joints  can  be 
carried  out.  After  this  movable  plaster  casing  is 
used  (;i.e.  plaster  casing  cut  through  on  both  sides 
after  fixation,  then  removed  and  reapplied  with  ban- 
dages) .  In  every  fracture  careful  examination  should 
be  made  to  see  if  there  is  any  injury  to  the  nerves,  so 
that  paralysis  appearing  later  on  may  not  be 
unjustly  attributed  to  the  bandages. 

In  severe  cases  of  ischaemic  muscular  contracture, 
resection  of  several  centimeters  of  the  radius  and 
ulna  may  be  performed,  whereby  the  flexed  position 
of  the  fingers  and  hand  is  corrected  and  a  certain 
amount  of  function  is  restored. 

In  cases  where  the  nerves  are  implicated,  transpo- 
sition of  the  large  nerve  trunks  from  the  shrunken 
muscles  above  the  fascia  has  been  successfully  per- 
formed. 

Fig.  63  represents  a  case  of  ischaemic  muscular 
contracture  without  implication  of  the  nerves,  result- 
ing from  the  application  of  plaster  of  Paris  bandages 
to  a  supracondyloid  fracture  of  the  humerus.  The 
bandages  were  left  on  for  four  weeks,  in  spite  of 
pain,  swelling  and  blueness  of  the  fingers  occurring 
soon  after  their  application.  After  removal  of  the 
bandages,  the  muscles  of  the  forearm  were  found  to 
be  much  atrophied.     The  hand  and  fingers  gradually 

124 


assumed  the  form  of  claw-hand,  so  that  the  patient 
could  not  use  his  arm.  Extensive  resection  of  the 
radius  and  ulna  with  subsequent  suture  corrected 
the  flexed  position  of  the  hand  and  restored  the 
function  of  the  limb  to  a  certain  extent. 


125 


HALLUX  VALGUS  {Hammer-toe — Arthrogenous  Contracture) 
Plate  XLIX,  Fig.  64. 

In  the  foot  contractures  occur  which  are  generally 
limited  to  the  first  and  second  toes.  Pointed  shoes 
cause  external  deviation  of  the  great  toe,  known  as 
hallux  valgus.  The  deviation  may  be  as  much  as 
fifty  degrees,  so  that  the  great  toe  lies  over  or  under 
the  second  toe.  As  the  result  of  changes  in  the 
joint  (atrophy,  inflammation,  arthritis  deformans), 
arthrogenous  contracture  takes  place  in  the  meta- 
tarso-phalangeal  joint,  so  that  in  advanced  cases 
the  deformity  cannot  be  corrected.  Over  the  pro- 
jecting metatarso-phalangeal  joint  exostoses,  clavus 
and  bunions  may  develop,  while  an  ingrowing  toe- 
nail usually  forms  on  the  outer  side  of  the  great  toe 
(Fig.  99).  Clavus  most  commonly  forms  a  circum- 
scribed thickening  of  the  horny  layer  of  the  epider- 
mis, causing  pain  by  pressure  on  the  papillary  nerve 
endings.  Underneath  the  clavus  a  bursa  generally 
forms  which  may  suppurate  (bunion)  and  perforate 
externally  or  into  the  joint.  Clavus  most  often  occurs 
on  the  first  and  fifth  toes.  In  hallux  valgus  and  in 
hammer-toe  clavi  are  always  found,  often  between 
two  toes  or  under  the  toe-nails.  Subungual  exos- 
toses also  occur  in  these  cases  (Fig.  140). 

Hammer-toe  is  an  arthrogenous  flexion  contrac- 
ture usually  aflFecting  the  second  toe,  as  the  result  of 
wearing  too  short  boots,  or  secondary  to  hallux 
valgus.  The  first  phalanx  is  extended,  the  second 
and  third  flexed.     The  third  toe  is  rarely  affected. 

Hallux  valgus  and  hammer-toe  are  often  com- 
bined with  flat  foot,  and  then  render  walking  still 
more  awkward  and  painful. 

126 


Bockenheimer,  Atlas. 


Tab.  XLIX. 


Fig.  64.    Hallux  valgus  —  Hamtnerzehe  —  Arthrogciie  Kontraktur. 


Rcbm.in  Corap.nny,  New- York. 


Treatment.  Prophylactic  treatment  consists  in 
attention  to  tlie  feet,  baths,  cutting  the  toe-nails 
straight  instead  of  curved,  properly  made  boots,  etc. 

Hallux  valgus,  if  it  gives  much  trouble,  is  best 
treated  by  cuneiform  osteotomy  of  the  metatarsus 
and  subsequent  correction  in  plaster  of  I*aris. 

Hammer-toe  is  often  treated  by  fixation  to  a  splint, 
after  correction  of  the  deformity,  but  this  is  unsatis- 
factory. It  is  better  to  cut  through  the  soft  parts  at 
the  seat  of  flexion,  and  resect  the  joint  from  the 
extensor  surface;  or  in  bad  cases  to  disarticulate 
the  toe. 

Exostoses  can  be  chiseled;  subungual  exostoses 
after  removal  of  the  nail. 

Clavi  are  best  removed  by  the  knife.  In  subun- 
gual clavus  the  nail  must  be  removed  first.  Fistula 
from  a  bunion  should  be  freely  incised  and  cau- 
terized; or  the  whole  bursa  may  be  extirpated. 
(For  the  treatment  of  ingrowing  toe-nail  and  flat 
foot  see  Figs.  99  and  83). 

Fig.  64  shows  the  result  of  neglect  and  badly 
fitting  boots.  The  great  toe  shows  typical  hallux 
valgus.  On  the  inner  side  of  the  metatarso-pha- 
langeal  joint  is  a  clavus,  on  which  opens  a  fistula 
from  a  bunion  lying  under  it.  On  the  outer  side  of 
the  great  toe  the  nail  is  ingrowing.  The  second  toe 
is  affected  with  hammer-toe  and  also  clavus.  The 
back  of  the  foot  is  covered  with  dry  eczema,  due  to 
uncleanliness.  Owing  to  these  disorders  and  a  con- 
siderable degree  of  flat  foot  the  patient  could  hardly 
walk.  The  hallux  valgus  was  corrected  by  cunei- 
form osteotomy  of  the  metatarsus.  The  cla\Tis  and 
bunion  were  excised,  and  the  second  toe  disarticu- 
lated. The  eczema  healed  quickly  with  Hehra's 
ointment.  After  this  the  patient  could  walk  nor- 
mally, with  a  well-made  boot. 


127 


RHACHITIS— IWFRACTIONES  CRURIS  UTRIUSQUE 

{Rickets,  Greenstick,  Fractures  of  Both  Legs) 
Plate  L,  Fig.  65. 

Rickets,  which  is  also  known  as  the  EngUsh  dis- 
ease, is  a  disturbance  of  growth  affecting  the  whole 
skeleton.  It  consists  in  softening  of  the  bones  in  the 
course  of  their  growth,  from  defective  ossification 
due  to  deficiency  in  calcium  and  magnesium  phos- 
phates. In  the  epiphyses  there  is  abnormal  prolif- 
eration of  cartilage,  and  at  the  same  time  imperfect 
calcification  of  the  cartilage.  This  causes  thicken- 
ing of  the  epiphyses  and  interference  with  the  growth 
of  the  long  bones  in  rickety  children.  Irregularity 
in  the  formation  of  the  medullary  spaces  also  plays  a 
certain  part.  In  the  flat  bones  growth  in  thickness 
is  hindered. 

In  the  skull  the  disease  affects  chiefly  the  frontal 
and  parietal  bones.  The  bony  substance  may  be  so 
poorly  developed  that  the  bones  are  soft  and  flattened, 
yielding  to  pressure  (cranio-tabes) .  In  other  places, 
especially  the  frontal  and  parietal  eminences,  the 
bones  are  thickened  and  prominent  from  the  over- 
formation  of  bony  tissue.  The  cranial  sutures  and 
fontanelles  remain  open  for  a  long  time,  and  hydro- 
cephalus is  often  present.  The  upper  and  lower 
maxillae  are  flattened  and  irregularly  developed,  and 
the  implantation  of  the  teeth  is  irregular  and  abnor- 
mal. 

The  weight  of  the  body  causes  bending  of  the 
softened  bones;  the  spine  becomes  kyphotic  or 
scoliotic;  the  thorax  is  constricted  laterally,  and  the 
junctions  of  the  cartilage  and  bone  of  the  ribs  become 
thickened  (beaded  ribs  or  rickety  rosary) .      The  pel- 

128 


Bockenlieinier,  Atlas. 


Tib.  I., 


Fig.  05.    Rliacliilib.         Inlraclioiieb  cruris  iitriubL|iie. 


P(.hTn.in    r'ft«. XI \'__1. 


vie  bones  remain  small,  so  that  the  rickety  pelvis  is 
a  cause  of  obstructed  labor.  Lastly,  in  severe  cases, 
the  lower  extremities  become  extremely  bent  and  the 
bones  are  liable  to  greenstick  fracture. 

In  the  second  year  there  is  usually  thickening  of 
the  epiphyses  of  the  bones  of  the  limbs,  especially 
the  lower  ends  of  the  ulna,  radius  and  tibia;  while 
the  diaphyses,  especially  of  the  femur,  tibia  and 
fibula  are  curved.  The  femurs  are  bent  outwards, 
the  bones  of  the  leg  outwards  and  forwards  (Fig. 
65).  Genu  valgum  occurs  in  the  knees.  The  arch 
of  the  foot  sinks  in,  causing  flat  foot.  In  severe 
cases  of  rickets  the  children  remain  so  backward  in 
growth  that  they  become  dwarfs.  The  so-called 
fetal  rickets,  according  to  recent  investigations,  has 
nothing  to  do  with  rickets.  True  rickets  occurs 
exclusively  in  children  between  the  first  and  sixth 
years,  especially  in  the  second  year,  and  at  puberty 
as  late  rickets,  especially  when  heavy  weights  act  on 
the  limbs  (genu  valgum,  coxa  vara,  scoliosis,  pes 
valgus). 

The  origin  of  rickets  and  its  absence  in  certain 
countries  (China,  Japan,  Australia)  is  not  yet  quite 
clear,  but  bad  hygienic  conditions  and  especially 
improper  feeding  play  an  important  part.  Hered- 
itary syphilis  is  a  predisposing  cause. 

The  disease  often  begins  with  anaemia,  digestive 
troubles  and  diarrhea,  while  spasm  of  the  larynx 
(laryngismus  stridulus)  or  lung  affections  often 
occur  and  may  be  fatal. 

Differential  Diagnosis.  Osteomalacia,  which 
consists  in  softening  of  normally  developed  bones, 
occurs  at  a  later  age,  more  often  in  women.  Hered- 
itary syphilis  affects  fewer  bones,  especially  the 
tibia,  and  is  almost  always  associated  with  other 
signs  of  congenital  syphilis — interstitial  keratitis, 
notched  teeth,  etc.). 

Rickety  scoliosis  and  kyphosis   are   distinguished 

129 


from  tuberculous  spinal  disease  by  the  presence  of 
rickety  changes  in  other  parts  of  the  body. 

The  prognosis  is  favorable  on  the  whole.  Calcifi- 
cation may  take  place  in  the  osseous  tissue  and  the 
bones  may  assume  a  sclerotic  condition,  without  a 
trace  of  shortening  or  bending  being  left.  Accord- 
ing to  the  researches  of  von  Schlauge  and  Veil  this 
occurs  in  the  course  of  four  years  in  all  children  who 
do  not  remain  markedly  backward  in  growth.  The 
disease  generally  comes  to  an  end  about  the  sixth  year, 
but  it  may  recur  afterwards,  especially  in  the  winter. 

Treatment.  In  the  first  place  hygienic  condi- 
tions must  be  improved.  Infants  should  be  suckled 
by  the  mother.  Later  on  meat,  eggs  and  vegetables 
should  be  prescribed.  Fresh  air,  high  altitudes  and 
sea  bathing  are  all  beneficial.  Internally  cod-liver 
oil  and  phosphates.  The  children  should  be  kept 
off  their  feet,  and  sleep  on  hard  beds.  Surgical 
treatment  consists  in  the  treatment  of  green-stick 
fractures  and  in  correcting  the  curvature  of  the  bones 
of  the  limbs.  Complicated  apparatus  only  leads  to 
atrophy  of  the  limbs.  Ricketty  spine  should  be 
treated  by  a  strong  corset. 

Curvatures  of  the  bones  should  only  be  operated 
on  when  they  are  severe,  and  then  only  when  the 
disease  has  come  to  a  standstill.  An  X-ray  exam- 
ination is  useful;  in  active  rickets  the  epiphyseal 
lines  appear  wide  and  irregular,  sometimes  with 
incomplete  fractures  and  irregular  arrangement  of 
cartilage,  and  the  cortex  appears  much  thinned; 
while,  in  quiescent  rickets,  the  epiphyseal  lines  have 
become  regular,  and  the  cortex  appears  the  same 
thickness  as  the  deeper  parts. 

As  a  rule,  operation  should  not  be  performed 
before  the  sixth  year.  The  curvature  can  be  cor- 
rected manually  or  by  the  osteoclast;  better  still  by 
linear  or  cuneiform  osteotomy,  followed  by  plaster 
of  Paris. 

130 


Operation  is  also  indicated  in  cases  where  there  is 
early  sclerosis  of  the  bone,  which  is  shown  by  the 
X-rays.  In  this  case  the  curvature  must  be  cor- 
rected by  osteotomy,  otherwise  the  bones  will  be 
arrested  in  growth. 


O' 


Fig.  65  shows  rickets  affecting  the  whole  skeleton 
in  a  girl  aged  four  years.  The  left  femur  was  so 
much  curved  and  sclerosed  that  osteotomy  was  per- 
formed, while  the  curvature  of  the  right  femur  under- 
went spontaneous  cure.  The  epiphyses  of  the  knee 
and  ankle  joints  are  much  thickened,  the  upper  and 
lower  ends  of  the  tibias  are  much  bent.  At  the  lower 
ends  the  X-rays  showed  green-stick  fractures.  Oper- 
ation here  was  contra-indicated,  as  the  X-rays  showed 
the  disease  to  be  still  in  an  active  state.  In  the  hip 
joints  the  X-rays  showed  coxa  vara  of  the  neck  of 
the  femur.  The  child  was  very  feeble  and  backward 
in  growth. 


131 


LUXATIO  CUM  FRACTURA  CRURIS 

{Fracture-dislocation  of  the  leg) 
PSEUD  ARTHROSIS 

Plate  LI,  Fig.  66. 

False  joints  (pseudarthrosis)  occur  in  the  leg, 
chiefly  after  oblique  fractures  with  dislocation,  or 
comminuted  fractures;  in  the  thigh  and  upper 
arm  after  transverse  fractures  also,  as  the  result  of 
interposition  of  the  soft  parts,  chiefly  the  muscles. 
Advanced  age,  pregnancy,  rickets,  syphilis,  tuber- 
culosis, may  delay  union  of  the  fragments  in  a  frac- 
ture- 
Extension  treatment  is  the  best  to  obtain  rapid  and 
sure  union.  Delayed  union  may  be  accelerated  by 
percussion  of  the  fragments,  injection  of  iodine  and 
other  preparations,  or  of  blood,  into  the  callus;  by 
passive  hyperaemia,  or  by  the  administration  of 
phosphate  of  lime. 

Badly  united  fractures  can  be  brought  into  better 
position  by  the  osteoclast  or  by  osteotomy. 

In  the  treatment  of  pseudarthrosis  situated  close 
to  a  joint  resection  comes  into  question.  Pseudar- 
throsis in  the  shaft  can  be  repaired  by  bone  suture. 
When  the  ends  of  the  fragments  are  much  atrophied 
(X-ray  examination)  they  must  be  resected  before 
suturing.  The  fragments  may  be  resected  so  as  to 
overlap  each  other  (dovetailed).  The  periosteum 
must  always  be  spared  as  much  as  possible. 

Transplantation  of  bone  has  sometimes  proved 
successful.  If  no  union  occurs  after  these  methods, 
apparatus  must  be  worn,  or  amputation  must  be 
performed. 

132 


Bockenheinier,  Atlas. 


Fig.  66.    Luxatio  cum  liactura  cruris  —  Pseudartlirosis. 


Rfbman  Company,  Ncw-Vork, 


In  the  treatment  of  fractures  and  dislocations, 
especially  in  fracture-dislocations,  the  X-rays  are 
especially  useful  in  making  an  early  diagnosis. 

Fig.  66  shows  marked  deformity  of  the  lower  part 
of  the  right  leg  as  far  as  the  ankle  joint.  On  the 
outer  side  there  is  slight  outwai'd  curvature  of  the 
fibula  above  the  external  malleolus.  The  peripheral 
end  of  the  fibula  is  dislocated,  so  that  the  external 
malleolus  projects  and  the  skin  bulges  on  the  outer 
side  of  the  ankle  joint.  There  is  an  outward  curva- 
ture of  the  right  tibia  above  the  inner  malleolus.  The 
foot  is  in  the  position  of  advanced  flat-foot. 

The  nature  of  the  injury  is  an  ununited  supra- 
malleolar oblique  fracture  of  the  tibia.  The  distal 
part  of  the  tibia  is  freely  movable,  although  the  frac- 
ture is  of  two  years  standing.  X-ray  examination 
shows  that  the  fragments  have  overlapped,  and  that 
there  is  a  united  fracture  of  the  distal  end  of  the 
fibula  a  few  centimeters  above  the  external  malleolus, 
in  the  position  of  the  above-mentioned  projection. 

The  patient  (aged  sLxty),  owing  to  effusion  into  the 
left  knee  and  left  flat  foot,  depended  entirely  on  the 
right  leg;  the  injury  being  due  to  the  giving  way  of 
the  right  foot  in  a  position  of  supination.  The  frac- 
ture dislocation  had  not  been  diagnosed,  and  the 
patient  had  been  treated  with  poultices,  etc.  The 
foot  was  brought  into  proper  position  by  resection  of 
the  lower  ends  of  the  tibia  and  fibula  and  freshening 
the  head  of  the  astragalus. 


133 


Naevi 


N^VUS  PIGMENTOSTJS  PILOSUS  {Hairy  Pignwntary  Nwvus) 
Plate  LII,  Fig.  67. 


Nsevi  (or  birthmarks)  are  congenital,  fibrous  new 
formations  of  the  skin.  Lentigines  and  ephelides 
(freckles)  resemble  nsevi  in  their  histological  struc- 
ture. 

Only  the  larger  nsevi  are  present  at  birth;  the 
rest  develop  during  childhood  and  cease  growing  at 
puberty. 

Naevi  formed  of  blood-vessels  are  called  vascular 
naevi  (Figs.  75  and  76),  while  those  formed  of  lymph- 
atics are  known  as  lymphangiectasis. 

A  special  form  of  nsevus  is  the  pigmentary  nsevus. 
Owing  to  the  presence  of  lymphatics  this  is  called  by 
V071  Recklinghausen  lymphangio-fibroma,  by  Borst 
fibroma  melanodes.  These  are  often  covered  with 
hairs  and  are  also  known  as  pigmented  hairy  nsevi 
(Fig.  67).  In  pigmentary  nsevi  there  is  proliferation 
of  fibrous  cells  in  the  dermis,  dilatation  of  lymphatic 
vessels,  and  pigment  within  the  cells  of  the  dermis 
and  epidermis. 

These  naevi  are  round,  oval,  or  irregular  in  shape, 
with  a  sharply  defined  margin,  and  brown,  yellowish- 
brown,  blackish-brown  or  black  color.  Clinically 
they  are  divided  into  two  forms,  flat  nsevi,  on  a  level 
with  the  skin,  and  projecting  nsevi. 

Flat  nsevi  occur  on  one  side  or  over  the  whole 
body.  Their  distribution  sometimes  corresponds  to 
that  of  the  cutaneous  nerves,  and  on  this  account 
their  origin  has  been  attributed   to  trophic  changes 

134 


Bockenheimer,  Atlas. 


Tab.  I.II. 


Fig.  67.    Naevus  pijj;mentosus  pilosus. 


in  the  spinal  ganglia,  also  to  fibromas  of  the  smallest 
cutaneous  nerves.  In  elephantiasis  of  nerves  flat 
nsevi  are  generally  found  on  the  body.  Projecting 
nsevi,  especially  pigmentary,  often  have  a  surface 
resembling  that  of  a  wart,  and  may  assume  a  villous 
appearance.  Lastly,  papillomas,  carcinomas  and 
sarcomas  may  arise  from  nievi. 

As  a  rule,  nsevi  cause  no  trouble,  but  occasionally 
they  may  become  ulcerated. 

Differential  Diagnosis.  Nsevi  may  have  some 
resemblance  to  warts,  fibromas  and  pityriasis  versi- 
color, but  the  diagnosis  is  usually  easy. 

Treatment.  On  exposed  parts  of  the  body  nsevi 
should  be  excised,  for  cosmetic  reasons.  Removal  is 
also  indicated  in  rapidly  growing  naevi,  and  when 
inflammation  occurs. 

Ephelides  may  be  removed  by  the  application  of 
strong  resorcin  paste. 

Fig.  67  shows  a  very  extensive  pigmentary  hairy 
naevus  which  was  present  at  birth,  and  increased  in 
size  till  the  age  of  puberty.  The  borders  are  smooth, 
but  the  central  parts  of  the  surface  are  warty  (nsevus 
verrucosus).  The  color  is  blackish  brown  in  the 
center  and  brown  at  the  periphery. 


135 


N^VUS  NEUROMATOSUS— FIBROMA  CUTIS 

{Cutaneous  Fibroma) 
Plate  LIU,  Fig.  68. 

The  distribution  of  certain  nsevi  in  the  course  of 
nerves  has  been  already  mentioned.  Von  Reckling- 
hausen  was  the  first  to  show  the  connection  between 
disseminated  pigment  spots  and  nervous  diseases. 
The  researches  of  Soldan  have  shown  that  in  pig- 
mentary nfevi  the  presence  of  nerves  can  be  demon- 
strated, in  the  sheaths  of  which  fibromas  develop 
which  can  only  be  seen  with  the  microscope,  but 
arise  like  the  larger  fibromas  of  nerve  sheaths;  also 
that  they  appear  in  the  form  of  multiple  soft  tumors 
(fibroma  moUuscum),  or  as  congenital  elephantiasis 
of  nerves. 

Fig.  68  shows  a  slightly  pigmented  naevus  extend- 
ing over  most  of  the  forearm,  with  a  bluish-red, 
irregular  elevation  in  the  center.  The  presence  of 
numerous  small,  soft  nodules  in  the  skin  (fibromata 
mollusca);  also  the  presence  of  a  small  projecting 
growth,  painful  on  pressure,  which  is  formed  by  a 
fibroma  of  the  nerve  sheath  of  a  large  subcutaneous 
nerv'e,  shows  it  to  be  a  case  of  noevus  neuromatosus. 
Multiple  cord-like  formations  could  be  felt  under 
the  naevus,  which  were  probably  plexiform  neuromas. 
Pigmentary  spots  were  present  over  the  whole  body, 
and  fibromata  the  size  of  a  nut  on  the  upper  arm  and 
axilla. 

Fibromas  of  nerve-sheaths  have  been  incorrectly 
called  neuro-fibromas;  but  they  consist  of  fibrous 
tissue  only,  without  any  proliferation  of  nerve  fibres. 
They  are  generally  multiple  and  disseminated  over 
the  whole  body,  forming  small,  soft  fibromas  when 

136 


Bockenheimer,  Atlas. 


Tab.  LI  I 


Fig.  68.  Naevus  neuromatosus  —  Neurofibroma  cutis. 


Rcbman  Company,  New- York. 


they  affect  the  fine  cutaneous  nerves,  and  are  com- 
bined with  numerous  pigment  spots  (neuro-fibro- 
matosis  of  von  Recklinghausen) .  The  small  tumors 
may  He  so  closely  together  that  the  skin  assumes  a 
finely  lobulated  appearance  (temples,  neck  and  back). 
This  condition  has  been  termed  elephantiasis  ner- 
vorum, and  consists  in  fibrous  tissue  formation  with 
lymphatic  vessels  (Fig.  69).  The  disease  is  either 
congenital  or  appears  at  an  early  age,  and  is  due  to 
developmental  disturbances.  There  is  sometimes 
also  a  hereditary  predisposition. 

In  distinction  to  these  small,  soft,  multiple  fibro- 
mas,  fibromas  of  the  larger  nerve  trunks  appear  as 
hard  fusiform  tumors  of  the  sheaths  of  the  cutaneous 
(Fig.  68)  or  subcutaneous  nerves.  They  are  very 
painful  on  pressure.  Functional  disorders  occur  in 
the  form  of  paraesthesia. 

In  addition  to  these  two  forms  of  fibroma,  there 
are  true  neuromas  which  resemble  cirsoid  aneurism, 
and  are,  therefore,  called  cirsoid  neuroma  or  plexi- 
form  neuromas.  These  are  formed  of  twisted  cords 
which  may  form  an  inextricable  network  of  nerve 
cords. 

In  distinction  to  the  fibromas  of  nerve-sheaths,  in 
which  there  is  no  new  formation  of  nerve  fibers,  there 
is  in  true  neuromas  a  new  formation  both  of  fibrous 
tissue  and  nerve  fibers,  which  is  due  to  developmental 
disturbance,  which  generally  appears  at  birth,  and 
chiefly  affects  the  scalp,  temples,  nape  of  the  neck 
and  the  back.  In  this  case  also  there  occur  combi- 
nations with  pigment  spots,  fibromatosis,  fibromas 
of  nerve-sheaths  and  elephantiasis  of  nerves. 

Differential  Diagnosis.  Isolated  fibromas  of 
nerve-sheaths  may  be  mistaken  for  other  tumors, 
but  there  are  generally  other  anomalies  present,  such 
as  pigment  spots,  etc. 

Treatment.  Naevus  neuromatosus  should  only 
be  excised  when  it  shows  papillomatous  proliferation, 

137 


or  when  fibromas  or  plexiform  neuromas  are  situated 
beneath  it. 

Isolated  fibromas  of  the  nerve  sheaths  can  generally 
be  excised  without  injuring  the  nerve;  but  in  large 
fibromas  the  nerve  may  have  to  be  removed,  with 
subsequent  nerve  suture.     Recurrence  is  rare. 

Multiple  fibromas  are  apt  to  recur  after  operative 
interference,  which  seems  to  show  that  irritation 
and  trauma  favor  their  development.  Rapidly  grow- 
ing tumors  should  be  removed  as  they  may  undergo 
transformation  into  sarcoma  and  myxosarcoma. 

Plexiform  neuromas  must  be  completely  extirpated, 
as  recurrence  takes  place  if  any  part  is  left  behind. 
At  the  same  time  the  thickened  skin  should  be 
removed,  if  it  shows  elephantiasic  changes  (Figs. 
68  and  69).  In  extensive  cases  the  operation  may 
be  done  at  several  sittings. 

Fig.  68  shows  the  various  affections  mentioned 
above  in  the  left  arm  of  a  young  man.  The  extensive 
nsevus  pigmentosus  was  present  at  birth.  The 
smaller  nsaevus  neuromatosus,  and  the  multiple, 
small,  soft  fibromas  lying  in  it;  the  hard  fibroma, 
arising  from  the  sheath  of  a  large  nerve,  seen  at  the 
upper  end  of  the  nsevus  neuromatosus  near  the  bend 
of  the  elbow;  also  the  plexiform  neuroma  appearing 
in  the  subcutaneous  tissue  in  the  form  of  twisted 
cords,  all  developed  later,  but  had  been  present  many 
years.  Small  pigment  spots  were  present  all  over 
the  body.  There  were  also  fibromas  of  different  sizes 
in  the  course  of  the  different  nerves  of  the  same  arm. 
A  fibroma  situated  in  the  axilla  caused  much  pain, 
and  was  removed.  Excision  of  the  nsevus  neu- 
romatosus and  the  underlying  plexiform  neuroma 
was  performed  later. 


138 


Bockenheimer,  Atlas. 


Tab.  LIV. 


o 


ta 


n 
o 


c 
> 


o 


Rebman  Company,  New- York. 


ELEPHANTIASIS  NERVORUM  {of  the  Nerves) 
—FIBROMATA  MOLLUSCA 

Plate  LIV,  Fig.  69. 

Fig.  69  shows  a  similar  case  in  a  girl,  aged  twenty. 
The  whole  of  the  right  half  of  the  scalp,  the  right  side 
of  the  forehead  and  the  ear  are  the  seat  of  a  lobulated 
growth  (elephantiasis  nervorum)  fixed  on  the  head 
like  a  cap.  The  growth  was  congenital,  and  on  its 
surface  are  numerous  pigment  spots  and  soft,  small, 
painless  tumors  (fibromata  mollusca).  Numerous 
cord-like  formations  were  found  in  it  by  palpation 
(plexiform  neuroma).  The  tumor  was  partially 
removed  by  a  curved  incision,  the  scar  of  which  is 
shown  in  the  figure.  Total  extirpation  was  per- 
formed subsequently  at  several  sittings.  Microscopic 
examination  confirmed  the  above-mentioned  explana- 
tion of  the  affection,  the  lymphatic  vessels  being 
increased  and  dilated  in  the  region  of  the  tumor. 


139 


ACNE  ROSACEA— RHmOPHYMA 
Plate  LIV,  Fig.  70. 

Fig.  70  shows  an  irregular,  lobular  thickening  of 
the  nose,  along  with  changes  in  the  skin  of  the  face, 
in  an  old  man.  Commencing  as  acne  rosacea,  the 
affection  consists  in  a  dilatation  of  the  blood-vessels 
and  the  formation  of  new  blood-vessels,  giving  the 
face  a  dark-red  coloration,  which,  beginning  in  the 
nose,  may  spread  over  the  whole  face.  Later  on 
there  occurs  hyperplasia  of  the  connective  tissue  and 
sebaceous  glands,  giving  rise  to  brownish-red  or  bluish- 
red  nodules  in  the  nose  (rhiuophyma) .  The  whole 
skin  of  the  face  takes  part  in  the  thickening  in  a  lesser 
degree,  becomes  reddish-brown,  and  shows  numerous 
pits  representing  the  dilated  orifices  of  the  sebaceous 
glands.  From  these  pits  yellowish-white  secretion 
can  be  expressed.  There  are  often  numerous  acne 
pustules  on  the  face. 

The  origin  of  the  disease  has  been  attributed  to 
congenital  anomaly,  alcoholism,  indigestion,  diseases 
of  the  digestive  organs,  affections  of  the  genital 
organs,  and  influences  which  cause  congestion  of  the 
blood-vessels  of  the  head  {e.g.  cooks  who  are  exposed 
to  heat).     The  disease  usually  occurs  in  old  men. 

Differential  Diagnosis.  A  pachydermatous 
condition  of  the  skin  may  result  from  repeated 
attacks  of  erysipelas,  but  differs  from  rhinophyma  in 
not  affecting  the  nose  any  more  than  the  rest  of 
the  face.  Lupus  is  distinguished  by  its  apple-jelly 
nodules  and  ulceration. 

Rhinoscleroma  causes  softer  tumors  which  soon 
ulcerate,  and  may  destroy  the  whole  face. 

140 


Treatment.  In  the  early  stages  massage  of  the 
face  and  iuuuction  of  ichthyol-resorciii  ointment  (one 
to  ten  per  cent.)  are  useful.  Attention  should  be 
paid  to  the  diet  and  all  exciting  causes  avoided.  In 
rhinophyma  the  tumors  may  be  excised  or  treated 
with  Pacquelin's  thermo-cautery.  Good  results  have 
been  obtained  by  peeling  off  the  nodules  with  a 
sharp  knife  (decortication).  The  wound  is  soon 
covered  by  new  epidermis,  and  the  cosmetic  results 
are  very  satisfactory. 


141 


ELEPHANTIASIS  PENIS  LYMPHANGIECTATICA 

{Lymphangiedaiic  elephantiasis  of  the  penis) 
Plate  LV,  Fig.  71. 

In  distinction  to  congenital  elephantiasis  of  nerves 
there  is  a  second  form  of  elephantiasis  arabum,  which 
for  various  reasons  chiefly  affects  the  lower  extremi- 
ties, and  is  known  as  acquired  elephantiasis  or  pachy- 
dermia. It  consists  in  a  chronic,  inflammatory 
hyperplasia,  and  there  is  no  formation  of  true 
tumors.  There  is  diffuse  thickening  of  the  connec- 
tive tissue  (fibromatosis),  both  in  the  cutis  and  in  the 
subcutaneous  tissue.  Finally  the  muscles  are 
attacked  and  replaced  by  hyperplastic  connective 
tissue.  The  periosteum  of  the  bones  may  present 
osteophytic  deposits.  Lastly,  the  epidermis  takes 
part  in  the  proliferative  process,  so  that  the  skin 
becomes  thickened  and  horny,  or  eczematous. 

The  affected  parts  thus  become  greatly  thickened. 
The  thickening  may  be  uniformly  distributed,  or  may 
assume  a  lobulated  formation  as  in  elephantiasis  ner- 
vorum. In  addition  to  the  proliferation  of  connective 
tissue  there  is  always  dilatation  of  the  blood-vessels 
and  lymphatics.  The  disease  thus  appears  to  origi- 
nate in  lymphatic  engorgement,  and  the  proliferation 
of  connective  tissue  results  from  lymphatic  infiltration 
of  the  tissues. 

All  processes  which  give  rise  to  lymphatic  engorge- 
ment may,  in  certain  cases,  lead  to  elephantiasis. 
For  this  reason,  in  the  endemic  form  of  this  elephan- 
tiasis which  occurs  especially  in  Arabia,  Egypt,  Aus- 
tralia, and  generally  in  tropical  countries,  it  has  been 
assumed  that  the  parasites  (filaria  sanguinis)  block 
up  the  lymphatic  vessels,  causing  lymphatic  varices 
which  rupture  and  deluge  the  tissues  with  lymph, 

142 


Bockenheinier,  Atlas. 


Fig.  7].    Elepliaiiliasis  penis  lympliaiigiectatica. 


Rebman  Company,  Neu-Vork. 


and  give  rise  to  hyperplasia  of  the  connective  tissue. 
The  lymph  vessels  may  be  so  dilated  that  small  blad- 
ders filled  with  lymph  may  be  visible  on  the  surface 
of  the  skin. 

The  endemic  form  generally  has  an  acute  onset 
with  fever  and  lymphangitis.  After  the  acute  symp- 
toms have  subsided,  swelling  of  the  lower  extremities 
remains  behind.  Further  attacks  follow  which  cause 
increased  thickening.  Endemic  elephantiasis  princi- 
pally affects  the  scrotum,  penis,  and  female  genitals. 
As  in  the  sporadic  form,  the  thickening  is  soft  at  first, 
but  becomes  hard  later  on  from  diffuse  fibromatosis. 

Sporadic  elephantiasis  is  caused  by  affections  which 
give  vise  to  lymphatic  engorgement — chronic  oedema, 
recurrent  erysipelas,  chronic  inflammations  such  as 
tuberculous  and  syphilitic,  varicose  ulcer,  phlebitis 
and  thrombosis  of  veins,  and  purulent  inflammations 
(especially  streptococcus  infection).  The  lower  ex- 
tremities are  generally  affected,  often  in  women  with 
chronic  eczema  and  varicose  ulcer  (Fig.  72).  In 
prostitutes,  the  labia,  clitoris  and  perineum  some- 
times become  affected  with  elephantiasis,  from  gon- 
orrheal discharges  and  syphilis.  In  men,  the  penis 
may  be  affected,  especially  after  removal  of  the 
inguinal  glands  on  both  sides  (Fig.  71). 

In  elephantiasis  the  tissues  at  first  feel  soft,  after- 
wards firm  and  elastic.  Eczema,  bullae,  pigmenta- 
tions, scabs  and  crusts,  condylomatous  or  papillo- 
matous proliferation,  or  finally  ulceration  may  occur 
on  the  surface.  The  leg  or  scrotum  may  be  so  much 
thickened  that  the  patient  can  hardly  move.  Ulcer- 
ation causes  intolerable  suffering. 

Differential  Diagnosis.  Acquired  elephantiasis 
differs  from  elephantiasis  nervorum  in  the  nature  of 
its  origin,  and  in  the  absence  of  true  fibromas  and 
plexiform  neuromas.  In  partial  giantism  there  is  an 
overgrowi;h  from  early  infancy  of  all  the  tissues, 
including  the  bones. 

143 


Treatment.  As  endemic  elephantiasis  is  con- 
veyed by  means  of  drinking  water  and  parasitic 
insects,  precautionary  measures  must  be  taken  for 
its  prevention. 

In  sporadic  elephantiasis  all  chronic  inflammatory 
processes,  etc.,  which  excite  the  disease,  must  be 
avoided.  Bubos  should  be  incised  early  to  avoid 
lymphatic  obstruction,  and  ulcers  of  the  foot  must 
be  treated  (Fig.  72). 

In  slight  cases  of  elephantiasis  moderate  results 
have  been  obtained  by  elevation  of  the  limb,  massage 
and  injections  of  alcohol.  More  extensive  cases  may 
be  treated  by  cuneiform  excision.  Ligation  of  the 
arteries  of  the  skin  is  useless  and  dangerous.  In 
extensive  ulceration  of  the  leg,  amputation  may  be 
necessary. 

Fig.  71  shows  a  case  of  acquired  elephantiasis  of 
the  penis  and  scrotum  in  a  man,  aged  forty,  after 
extirpation  of  the  inguinal  glands  on  both  sides. 
According  to  the  patient  the  thickening  of  the  penis 
and  scrotum  developed  gradually  during  some  years, 
and  caused  no  inconvenience.  Still  greater  acute 
swelling  of  the  penis  often  developed  suddenly,  show- 
ing that  it  was  a  form  of  acquired  elephantiasis  which 
has  been  called  lymphangiectatic.  According  to  the 
patient  this  acute  swelling  subsided  after  a  few  days 
in  bed.  The  thickened  tissue  felt  soft  and  spongy, 
and  appeared  to  consist  of  several  lobulated  growths 
rather  than  uniform  thickening.  The  skin  was  pig- 
mented and  the  scrotum  covered  with  crusts,  and 
there  were  numerous  depressions  as  in  rhinophyma. 
The  patient  was  treated  by  suspension,  elastic  pres- 
sure, and  later  on  cuneiform  excision. 


144 


V.' 


/ 


Bockenheimcf,  Atlas. 


lab.  LVI. 


Fig.  72.    Ulcus  cruris  varicosum  —  Elephantiasis,  Pachydermia  acquisita. 


ULCUS   CRURIS   VARICOSUM  {Varicose  ulcer  of  the  leg) 
ELEPHANTIASIS  S.  PACHYDERMLA  ACQUISITA 

{Acfjuired  elcphaniias-is  or  pachydermia) 
Plate  LM,  Fig.  72. 

In  this  case  an  elephantiasic  thickening  of  the 
toes  has  developed  in  connection  with  a  varicose 
ulcer  of  the  leg;  which,  as  already  explained  (Plate 
LV),  is  due  to  connective-tissue  hyperplasia  of  the 
skin  resulting  from  lymphatic  engorgement  (acquired 
lymphangiectatic  pachydermia).  The  toes  are  enor- 
mously thickened,  and  constricted  in  places;  the 
whole  foot  is  also  enlarged,  and  the  arch  of  the  foot 
is  obliterated.  The  thickening  of  the  foot  contin- 
ually increased,  and  extended  to  the  ankle.  Frequent 
attacks  of  erysipelas  aggravated  the  affection. 

At  the  lower  third  of  the  leg,  on  the  inner  side,  is 
an  ulcer  extending  over  nearly  the  whole  circum- 
ference of  the  leg.  Ulcers  develop  in  this  situation 
from  various  causes — blows  on  the  leg,  chronic  ecze- 
ma, abscess,  erysipelas,  thrombo-phlebitis,  varicose 
veins,  burns  and  frost-bite. 

These  ulcers  are  most  commonly  connected  with 
disturbance  in  the  blood  and  lymphatic  circulation 
both  as  regards  their  origin  and  chronic  progress. 
They  generally  occur  in  old  people  of  the  poorer 
classes  who  have  to  do  much  standing,  and  are 
especially  aggravated  by  uncleanliness.  They  often 
occur  on  both  legs.  Arteriosclerosis,  diabetes,  and 
diseases  of  the  central  nervous  system  give  rise  to 
especially  obstinate  and  extensive  ulcers  (trophic 
ulcer) . 

Varicose  ulcer  of  the  leg  is  characterized  by  its 
irregular  slightly  raised  edges,  while  the  parts  round 

145 


the  ulcer  may  be  covered  with  scattered  flabby  granu- 
lations, crusts  and  blood-scabs  (Fig.  72).  There  is 
frequent  bleeding  from  the  dilated  veins  at  the  base 
of  the  ulcer.  The  ulcer  is  often  connected  with  a 
ruptured  varicose  vein.  In  small  ulcers  temporary 
healing  may  take  place,  but  the  scar  is  very  thin, 
generally  pigmented,  and  gives  way  again  on  the 
slightest  cause;  after  which  no  further  healing  usually 
takes  place,  but  the  ulcer  continues  to  extend.  The 
whole  neighborhood  of  the  ankle  joint,  and  even  the 
whole  leg,  may  be  involved  in  ulceration,  which  often 
has  a  sanious  discharge.  In  extensive  ulcers  there  is 
generally  severe  pain  and  the  leg  becomes  more  or 
less  useless  owing  to  the  extent  of  the  ulcer  and  the 
elephantiasis. 

Differential  Diagnosis.  Large  ulcers  with 
sanious  discharge  may  suggest  carcinoma,  owing  to 
their  hard  borders,  but  in  carcinoma  there  are 
always  irregular,  hard-tumor  masses  in  the  whole 
extent  of  the  ulcer.  The  possibility  of  transition  of 
an  ulcer  of  the  leg  to  carcinoma  must  be  borne  in 
mind. 

Gummatous  ulcer  is  more  regular,  often  circular, 
and  has  a  punched-out  appearance.  The  base  of 
the  ulcer  is  smooth  and  covered  with  a  tenacious  yel- 
lowish fatty  core.  The  ulcer  is  generally  less  exten- 
sive and  there  is  no  bleeding.  It  heals  quickly  under 
iodide  of  potassium.     (Fig.  1:23). 

Treatment.  To  improve  the  circulation,  rest  in 
bed  and  support  with  elastic  bandages  (flannel  or 
Japanese  mull)  are  absolutely  necessary.  In  cases 
with  extensive  varicose  veins  (Fig.  83)  ligation  of  the 
saphenous  vein  is  beneficial.  The  ulcer  itself  re- 
quires antiseptic  dressings  (iodoform,  Hebra's  oint- 
ment, Lassar's  zinc  paste,  balsam  of  Peru,  acetate  of 
aluminium).  The  application  of  fenestrated  com- 
pressing-bandages  with  Unnas'  zinc  gelatin  or  pep- 

146 


tonated  paste  is  also  recommended.  In  out-patient 
practice  compressing  bandages  of  mastich  or  starch 
may  be  used.  Compressing  bandages  should  be  left 
on  for  several  weeks,  and  the  ulcer  can  be  treated 
daily  through  the  hole  in  the  bandage. 

In  very  obstinate  ulcers  incisions  above  the  ulcer 
have  been  recommended  to  improve  the  circulation. 
Other  measures  are  scraping,  cauterization,  or  exci- 
sion of  the  whole  ulcer  followed  by  skin  grafting. 
Very  severe  cases,  and  those  suspected  of  carcinoma, 
may  require  amputation. 


147 


DECOLLEMENT  DE  LA  PEAU    {Detachment  0}  the  Skin) 
Plate  LVn,  Fig.  73. 

Detachment  of  the  skin  is  a  term  applied  by 
Morel-Lavallee  and  Kbhler  to  a  lesion  which  consists 
in  subcutaneous  separation  of  the  skin  from  the  sub- 
jacent tissues  and  fascia.  The  skin  itself  is  unin- 
jured, as  the  lesion  is  produced  by  a  force  acting  at  a 
tangent  which  separates  the  skin  from  its  foundations. 
The  lesion  is  more  liable  to  occur  in  the  neighborhood 
of  the  elbow  joint,  and  over  the  tibia  {e.g.  after  being 
run  over) .  Besides  the  detachment  of  skin  the  deeper 
structures  may  be  severely  injured  and  the  bones 
fractured.  The  blood-vessels  and  lymphatics  are 
injured,  giving  rise  to  effusion  into  the  newly  formed 
subcutaneous  space  and  bulging  of  the  skin.  If 
the  larger  blood-vessels  are  torn  there  is  subcutane- 
ous effusion  of  blood  and  dark-red  discoloration 
of  the  skin,  forming  an  extensive  tense  swelling 
which  generally  disappears  quickly.  If  the  larger 
lymphatic  vessels  are  torn,  as  usually  happens, 
the  lymphatic  effusion  often  appears  several  hours 
after  the  injury.  The  skin  is  hardly  altered,  per- 
haps somewhat  livid  and  excoriated,  while  the 
subcutaneous  swelling  subsides  slowly,  owing  to  the 
long,  continual  effusion  of  lymph. 

The  lymphatic  effusion,  which  is  generally  more  or 
less  mixed  with  blood,  accumulates  in  the  dependent 
parts  of  the  injured  region.  Fluctuation  of  the  fluid 
in  the  subcutaneous  cavity  can  be  felt. 

Treatment.  Subcutaneous  effusion  of  blood  soon 
undergoes  spontaneous  absorption.  The  lymphatic 
effusion  gradually  disappears  after  repeated  punc- 

148 


Bockeiiheimer,  Atlas. 


Tab.  LVl 


I'igf.  73.    Dclacluiicnt  of  tlie  Skin. 


P^hmsn    rrtmn^ni-      M^^-\'nrlf 


ture,  injection  of  tincture  of  iodine  and  compression 
by  bandages.  Incision  should  only  be  performed  if 
there  is  suppuration. 

Fig.  73  shows  a  detachment  of  the  skin  resulting 
from  a  blow  on  the  left  elbow.  A  few  days  after  the 
injury  effusion  took  place  in  the  subcutaneous  cavity, 
chiefly  in  the  forearm.  The  cavity  was  not  com- 
pletely filled  so  that  several  swellings  are  shown. 
There  is  a  slight  abrasion  of  the  skin  over  the  ole- 
cranon, the  appearance  and  direction  of  which  show 
that  the  blow  was  a  tangential  one.  The  skin  is  livid 
over  the  whole  swelling.  Yellowish  fluid  was  evacu- 
ated by  puncture,  showing  very  slight  mixture  with 
blood. 

Submucous  effusion  in  the  nasal  septum  and  in  the 
larynx  may  also  be  caused  by  the  action  of  tangential 
force  (generally  foreign  bodies).  Here  also  the  effu- 
sion only  occurs  where  the  submucous  tissue  is 
situated  over  a  hard  substratum  of  cartilage. 


149 


OTHAEMATOMA  (Hematoma  of  the  Ear) 
Plate  LVIII,  Fig.  74. 

The  majority  of  cases  of  hematoma  of  the  external 
ear  are  caused  by  a  tangential  force  which  tears  the 
perichondrium  from  the  cartilage  and  is  followed  by 
effusion  of  blood  or  lymph  into  the  subcutaneous 
cavity.  The  lesion  occurs  especially  in  the  upper 
half  of  the  auricle,  and  is  found  in  the  mentally 
affected  as  the  result  of  ill-treatment  by  blows  on  the 
ear,  etc.;  in  workmen  who  carry  loads  on  the  shoul- 
der which  graze  the  ear;  in  carpenters  through  car- 
rying planks;  in  butchers  through  carrying  troughs, 
etc.  It  is  also  a  common  injury  in  boxers  and 
acrobats.     It  generally  causes  little  trouble. 

Blood  effusion  is  indicated  by  the  rapid  develop- 
ment of  a  tense,  dark-blue  swelling  which,  after  a 
time,  subsides.  Lymph  effusion  is  indicated  by  a 
swelling  which  does  not  develop  till  some  time  after 
the  injury  and  has  less  tendency  to  subside;  the  skin 
is  not  discolored.  Lymph  effusion  is  nearly  always 
slightly  mixed  with  blood,  and  always  forms  a  tense 
swelling,  in  distinction  to  lymph  effusions  in  other 
parts.     (Fig.  73). 

Blood  and  lymph  effusions  in  the  auricle  may 
undergo  chronic  inflammation,  which  first  causes 
thickening,  later  on  atrophy  and  necrosis  of  the 
auricle,  with  considerable  mutilation.  If  the  skin 
is  much  abraded,  the  effusion  may  become  septic, 
with  consequent  destruction  of  the  cartilage. 

Differential  Diagnosis.  Cavernous  heman- 
gioma, which  often  occurs  in  the  upper  part  of  the 
auricle,  has  some  resemblance  to  hematoma.    Hem- 

150 


Bockenheimer,  Atlas. 


Tab.  LVIII. 


i;3 


in 


zr. 


SjO 


Rebman  Company,  N'cw-York. 


angioma,  however,  is  often  congenital;  it  forms  a 
tumor  which  can  be  diminished  by  pressure,  and  has 
a  bluish  coloration  and  an  uneven  surface.  Other 
vascular  anomalies  are  also  usually  present  in  the 
neighborhood  of  the  tumor. 


'ti^ 


Treatment.  Prophylactic  treatment  consists  in 
the  wearing  of  ear  caps.  The  hematoma  must  be 
protected  from  injuries  which  may  cause  septic  infec- 
tion of  the  effusion.  It  undergoes  spontaneous  reso- 
lution, but  more  slowly  than  in  other  places.  Lymph 
effusions  recur  after  repeated  puncture;  injection  of 
tincture  of  iodine  and  compression  by  strips  of  plaster 
are  not  of  much  value;  massage  is  useful  in  most 
cases.     If  suppuration  occurs,  they  must  be  incised. 

Fig.  74  shows  an  effusion  in  the  upper  third  of  the 
auricle.  The  patient  first  noticed  a  small  pimple, 
and  as  the  result  of  scratching  this  the  swelling 
gradually  developed;  at  first  soft,  afterwards  tense. 
The  skin  is  red,  not  bluish  red  as  in  blood  effusion. 
A  small,  blue  spot  in  the  figure  represents  the  original 
pimple.  The  condition  is  one  of  lymph  effusion. 
Lymph  mixed  with  blood  was  evacuated  by  puncture, 
but  the  swelling  recurred.  The  effusion  gradually 
subsided  after  massage. 


151 


HEMANGIOMA  SIMPLEX   (Simple  Hemangioma) 
Plate  LVIII,  Fig.  75  (of.  also  Figs.  76  and  81). 

The  term  Angioma  includes  new  growths  arising 
from  blood-vessels  and  lymphatics;  the  former  are 
called  hemangiomas,  the  latter  lymphangiomas. 
Hemangiomas  may  be  simple  or  cavernous  (cav- 
ernoma,  Figs.  36  and  80). 

The  red  spots  formed  by  tortuous  and  dilated 
blood-vessels  (telangiectasis,  nsevus  vasculosus)  are 
by  some  classed  as  tumors  and  included  among  the 
simple  hemangiomas;  by  others  they  are  considered 
as  hypertrophic  formations,  and  not  as  true  tumors, 
as  they  consist  in  dilatation,  lengthening  and  tor- 
tuosity of  the  vessels,  rather  than  new  formation  of 
vessels.  The  form  known  as  racemose  or  plexiform 
angioma  also  almost  always  consists  in  a  dilatation 
of  a  vascular  region,  not  a  true,  new  formation  of 
vessels.  It  is,  therefore,  better  to  give  the  name 
cirsoid  aneurism  to  these  formations,  which  are 
usually  congenital  and  due  to  fetal  remains,  but 
sometimes  traumatic.  Lastly,  neither  aneurisms  nor 
varices  belong  to  true  vascular  tumors.  The  red 
spots  with  more  or  less  regular  outlines,  often  only 
punctiform,  which  occur  in  the  skin  of  old  persons, 
are  also  not  true  tumors  but  only  dilated  and  tor- 
tuous blood-vessels  (telangiectases).  A  form  de- 
scribed by  Ziegler  as  hypertrophic  angioma  is  best 
named  hemangio-endothelioma,  as,  in  addition  to 
new  formation  of  vessels,  there  is  extensive  prolifera- 
tion of  the  endothelium. 

Clinically,  we  distinguish  telangiectases,  which  are 
situated  superficially  in  the  skin,  from  simple   hem- 

152 


angiomas  which  appear  in  the  skin  and  subcutaneous 
tissue.  The  latter  tumors,  also  called  angiomas 
(Fig.  75),  appear  as  raised  growths  with  well-defined 
borders.  The  overlying  skin  is  thin  and  adherent, 
and  of  a  reddish-blue  color.  In  places  there  are 
islands  of  normal  skin.  The  edges  of  cutaneous 
angiomas  are  dark-red,  slightly  raised,  and  often 
bordered  by  an  areola  of  fine  ramifying  blood-vessels. 
The  tumors  are  soft,  spongy,  somewhat  compres- 
sible, and  easily  movable  over  subjacent  parts.  They 
are  sometimes  present  at  birth  and  are  often  situated 
on  the  face,  lips,  cheeks  and  neck,  in  the  regions  of 
the  fetal  clefts.  In  other  cases  they  appear  soon 
after  birth,  usually  in  the  form  of  slow-growing  red 
spots.  Angiomas  distributed  in  the  region  of  the 
trigeminal  nerve  have  been  called  neuropathic  angio- 
mas.    Angiomas  may  also  develop  in  scars. 

More  extensive  growth  may  form  large,  nodular 
lobulated  tumors,  which  when  situated  in  the  orbit 
may  be  dangerous  from  extension  to  the  brain;  but 
they  cannot  be  regarded  as  malignant  tumors,  be- 
cause they  give  rise  to  no  metastases. 

Involution  of  angioma  has  been  observed  as  the 
result  of  inflammation.  Angiomas  are  usually  mul- 
tiple, cutaneous  or  subcutaneous.  They  may  also 
occur  in  the  muscles,  bones,  brain,  breast  and  liver, 
generally  in  the  form  of  cavernous  hemangioma. 
They  cause  no  trouble  apart  from  that  due  to  their 
disfigurement. 

Differential  Diagnosis.  The  tumors  are  so 
typical  that  they  cannot  easily  be  mistaken.  Sub- 
cutaneous hemangioma  generally  appears  later 
under  the  skin,  which  gradually  assumes  a  bluish 
coloration. 

Cavernous  hemangioma  (cf.  Figs.  36  and  80) 
appears  as  a  multilobular  swelling,  which  diminishes 
on  pressure.  When  it  forms  in  the  skin,  the  latter 
is  colored  bluish  green  (Fig.  81). 

153 


Treatment.  Large  hemangiomas  of  the  skin 
and  subcutaneous  tissue  are  best  excised,  especially 
when  situated  on  the  face.  Small  angiomas  can  be 
treated  by  multiple  puncture  with  the  thermocautery 
into  the  subcutaneous  fatty  tissue,  at  several  sittings 
(especially  in  subcutaneous  angiomas),  but  the  scars 
are  often  unsightly.  After  electrolysis  the  scars  are 
smoother  and  less  visible.  Angiomas  sometimes 
recur  in  the  scars. 

Angiomas  of  the  eyelids,  which  may  extend 
through  the  orbit  to  the  brain,  or  those  situated 
over  a  fontanelle  which  may  implicate  a  sinus,  also 
very  extensive  angiomas  of  the  face  are  not  suitable 
for  operation.  In  these  cases  the  introduction  of 
magnesium,  which  causes  coagulation  and  shrinking 
of  the  tumor,  may  be  tried. 

Fig.  75  shows  a  typical  simple  cutaneous  hem- 
angioma of  the  nape  of  the  neck,  which  appeared  as 
a  red  spot  soon  after  birth  and  ceased  growing  after 
the  second  year.  The  borders  of  the  growth  are  red 
and  show  small,  ramifying  blood-vessels.  The  cen- 
ter is  bluish  red  and  partly  covered  by  normal  skin. 
The  tumor  was  soft,  freely  movable  over  subjacent 
parts  and  sharply  defined.  It  was  excised  with  sub- 
sequent suture. 


154 


Bockenheimer,  Atlas. 


Tab.  LIX. 


o 


o 
> 


> 


t/3 


Rebman  Company,  New-Vork. 


HMVUS  VASCULOSUS  (Vascular  Nannui) 
Plate  LIX,  Fig.  76. 

In  distinction  to  the  projecting  hemangioma  we 
find  in  telangiectasis  a  flat  reddening  in  the  skin 
which  may  be  punctiform,  annular,  or  of  various 
shapes. 

The  greatest  degree  of  telangiectasis  is  attained  in 
the  so-called  vascular  naevus  which  most  often 
occurs  on  the  face,  and  is  either  congenital  or  appears 
soon  after  birth  as  a  red  spot.  This  rapidly  extends 
and  often  spreads  irregularly  over  half  the  face. 
The  edges  are  jagged  and  show  fine  ramifying  ves- 
sels. The  coloration  of  the  skin  varies,  and  there 
are  usually  different  tints  in  the  same  naevus.  It  is 
often  dark  purple  in  the  center  and  bright  red  at  the 
periphery.  It  is  often  broken  up  by  normal  skin, 
giving  a  variegated  appearance.  Spontaneous  invo- 
lution has  been  observed  in  small  naevi.  Apart  from 
the  disfigurement  they  cause  no  trouble. 

Treatment.  Good  results  have  been  obtained  by 
X-ray  treatment.  Cauterization  with  fuming  nitric 
acid  causes  the  naevi  to  disappear  and  leaves  smooth 
cicatrization.  (This  must  be  used  cautiously  on  the 
eyelids) . 


155 


HEMATOMA  DIFFUSUM  {Diffuse  Hematoma) 

—HEMOPHILIA 

Plate  LIX,  Fig.  77. 

Hemophilia  is  a  congenital  hemorrhagic  diathe- 
sis, which  presents  a  good  example  of  hereditary 
transmission,  as  it  is  well  established  that  there  are 
definite  families  of  bleeders.  As  a  rule  only  the  male 
descendants  are  bleeders,  but  the  hereditary  ten- 
dency is  transmitted  solely  through  the  female  line. 
Imperfect  coagulability  of  the  blood,  abnormal  ele- 
ments in  the  blood,  weakness  of  the  vessels,  or  vaso- 
motor dilatation  of  the  vascular  system  give  rise  to 
uncontrollable  and  exhausting  hemorrhage,  which 
may  occur  in  the  skin,  mucous  membranes,  joints  or 
internal  organs,  either  spontaneously  or  after  slight 
injuries.  The  effusion  in  the  skin  causes  purple 
coloration,  and  is  most  extensive  in  parts  where  the 
skin  is  more  loosely  attached  to  the  subcutaneous 
tissue  (eyelids,  Fig.  77).  A  subcutaneous  hem- 
atoma usually  forms,  which  may  be  very  extensive, 
especially  on  the  scalp,  where  it  generally  infiltrates 
the  periosteum.  Blood  effusions  into  the  skin,  sub- 
cutaneous tissue  and  periosteum  have  a  tendency  to 
continual  increase. 

In  addition  to  these  spontaneous  hemorrhages, 
bleeding  occurs  after  the  slightest  injuries,  such  as 
needle  pricks,  abrasions  of  the  skin,  tooth  extraction, 
and  even  after  cleaning  the  teeth.  The  blood  flows 
at  first  continually,  afterwards  intermittently,  and  is 
pale  and  watery.  In  larger  wounds  the  surface  is 
covered  with  blood-points,  and  oozes  like  a  sponge. 
The  most  dangerous  conditions  are  those  in  which 
an  injury  to  the  soft  parts  is  associated  with  abscess 
formation. 

156 


Bleeding  into  the  joints  causes  typical  honiarthro- 
sis,  which  is  recognized  by  the  "snowball  crunching" 
of  the  blood  clots  and  hemorrhagic  infiltration  of  the 
skin.  The  effusions  at  first  increase  intermittently 
and  later  on  become  stationary.  From  the  deposit 
of  fibrin  on  the  articular  ends  of  the  bones,  the  carti- 
lages may  be  extensively  destroyed,  with  resulting 
anchylosis  in  a  flexed  position,  or  subluxation.  How- 
ever, in  spite  of  numerous  bleedings  into  a  joint  com- 
plete recovery  of  the  joint  has  been  observed. 

Spontaneous  hemorrhage  in  the  kidneys  may  give 
rise  to  great  exhaustion.  The  diagnosis  is  established 
by  the  mode  of  origin  of  the  hemorrhage,  its  frequent 
occurrence  and  progressive  character.  Patients  gen- 
erally know  that  they  belong  to  a  family  of  bleeders, 
and  they  have  an  anaemic  appearance.  Many  cases 
are  fatal  from  repeated  bleeding. 

Differential  Diagnosis.  Scur\7,  which  causes 
bleeding  of  the  mucous  membrane  of  the  mouth  from 
ulceration,  only  causes  bleeding  in  the  skin,  joints 
and  other  organs  in  very  severe  cases. 

Purpura  hemorrhagica,  which  also  gives  rise  to 
hemorrhages  in  the  skin,  mucous  membranes  and 
organs,  may  be  difficult  to  diagnose  from  hem- 
ophilia unless  there  is  a  history  of  hereditary  ten- 
dency to  bleeding,  or  of  the  former  occurrence  of 
bleedings  pointing  to  hemophilia. 

Barlow's  disease  is  a  hemorrhagic  diathesis  occur- 
ring in  badly  nourished  infants,  which  give  rise  to 
subperiosteal  hemorrhages.  This  disease,  which  may 
also  cause  hemorrhage  into  the  skin  and  mucous 
membranes,  only  occurs  in  children  and  is  generally 
associated  with  rickets  (scurvy-rickets). 

Other  hemorrhages,  such  as  those  which  occur  in 
some  cases  of  hysteria,  in  vicarious  menstruation,  in 
certain  nervous  affections,  or  in  general  pyogenic 
infection,  are  not  so  extensive  as  those  of  hem- 
ophilia and  are  easily  distinguished  by  their  history. 

157 


Renal  hemorrhage  in  hemophilia  may  be  mis- 
taken for  renal  hemorrhage  due  to  other  causes 
(stone,  tumor,  tuberculosis),  but  the  bleeding  in 
hemophilia  quickly  leads  to  exhaustion,  and  gives 
no  evidence  of  other  changes  in  the  kidneys. 

The  hemarthrosis  of  bleeders  is  so  characteristic 
that  it  can  hardly  be  mistaken.  It  differs  from 
traumatic  hemarthrosis  in  its  progressive  increase 
and  slow  absorption.  Myeloid  sarcoma  extending  to 
the  joint  is  characterized  by  rapid  growth  and  the 
presence  of  a  malignant  tumor  (X-ray  examination), 
and  has  only  a  similarity  to  hemophilia  in  its  early 
stages. 

In  the  diffuse  bleeding  which  sometimes  occurs  after 
operations,  a  diagnosis  of  hemophilia  must  not  be  too 
hastily  made,  as  this  disease  is  quite  uncommon. 

Treatment.  Cutaneous  and  subcutaneous  blood 
effusions  should  be  left  alone;  puncture  is  useless, 
and  profuse  bleeding  often  takes  place  from  the 
puncture.  For  the  same  reason  puncture  of  a  joint 
effusion  with  injection  of  three  per  cent,  carbolic 
lotion  is  a  doubtful  procedure.  Compression  and 
extension  of  the  joint  is  the  best  treatment. 

Wounds  should  be  plugged  with  iodoform  gauze 
and  tightly  compressed.  Bleeding  from  the  gums 
and  nose  may  be  treated  with  the  thermocautery. 
Bleeding  after  tooth  extraction  may  be  averted  by 
plugging  the  socket  with  a  wedge  of  cork. 

The  most  difficult  cases  are  those  in  which  bleed- 
ing occurs  in  extensive  injuries,  especially  when  there 
is  suppuration.  The  application  of  perchloride  of 
iron  stops  the  bleeding  for  a  time,  but  forms  a  scab, 
and  after  this  becomes  loose  bleeding  recurs.  There 
is  also  the  danger  of  embolism  and  septic  infection. 

It  is  better  to  use  hot  gelatin  solution.  This  must 
be  carefully  sterilized  before  use  to  free  it  from 
tetanus  spores,  and  should  always  be  used  freshly 
prepared,   in  a  ten  per    cent,   solution.     Gelatin   is 

158 


also  useful  administered  internally  or  by  subcuta- 
neous injection.  In  extensive,  uncontrollable  bleed- 
ing affecting  the  extremities  amputation  may  have 
to  be  considered;  in  this,  all  the  vessels  must  be 
carefully  ligatured. 

In  renal  hemophilia  nephrotomy  and  nephrectomy 
has  proved  successful. 

During  the  bleeding,  which  often  ceases  sponta- 
neously after  a  time,  the  patient's  general  condition 
must  be  kept  up  by  forced  nourishment.  Bleeders 
must  naturally  avoid  everything  which  may  cause 
bleedinsr. 


't)' 


Fig.  77  shows  blood  effusion  into  the  subcutaneous 
and  subconjunctival  tissue  of  both  eyelids,  and  an 
extensive  hematoma  on  the  left  side  of  the  forehead 
in  a  child  aged  six  years,  who  belonged  to  a  family  of 
bleeders.  The  effusions  occurred  spontaneously;  the 
one  on  the  forehead  occurred  intermittently  for  a 
time  and  then  gradually  subsided.  There  was  no 
bleeding  in  any  other  part  of  the  body. 


159 


SUGGILLATIONES  ET  SUFFUSIONES 

{Suggillations  and  Snffrmons) 

HiEMATOMA  SUBCUTANEUM  (Subcutaneous  Hematoma) 
Plate  LX,  Fig.  78. 

Hemorrhages  into  the  skin  when  of  small  extent 
are  called  petechise  or  ecchymoses  (Fig.  79) ;  when 
of  larger  extent  suggillations  or  suffusions  (Fig. 
79).  Hemorrhages  into  cavities  are  called  hema- 
tomas. The  latter  often  occur  in  the  subcutaneous 
tissue,  giving  rise  to  convex  swellings  of  the  skin 
(Fig.  77).  Subcutaneous  hematomas  are  common 
after  all  kinds  of  injury — gunshot  wounds,  fractures, 
contusions,  punctured  wounds,  etc. ;  also  as  the  result 
of  secondary  hemorrhage  after  operations.  In  these 
cases  the  skin  assumes  first  a  purple,  afterwards  a 
greenish-yellow  coloration,  which  extends  beyond  the 
area  of  the  hematoma  and  persists  for  several  weeks. 
There  is  often  a  visible  swelling  with  fluctuation. 
Patients  complain  of  slight  pain  and  a  feeling  of 
tension.  If  the  swelling  persists,  the  sensation  of 
"snowball  crunching,"  which  is  characteristic  of  all 
blood  effusions,  is  felt  by  palpation. 

In  parts  where  the  skin  is  loosely  attached,  as  in 
the  eyelids  (Fig.  77)  or  scrotum,  there  is  much 
swelling  and  discoloration  of  the  skin.  After  injury 
to  a  large  blood-vessel,  enormous,  often  pulsating, 
swellings  may  occur  (pulsating  hematoma  or  false 
aneurism) . 

Subcutaneous  hematomas  usually  have  ill-defined 
margins,  owing  to  their  gradual  extent  into  the  soft 
parts.  Sometimes,  however,  they  become  encap- 
suled,   and   periosteal   hematomas  of  the  scalp  are 

160 


Bockenlieimer,  Atlas. 


Tab.  LX. 


1 

•Tt 


CO 


surrounded   by   a   wall  of   bony  hardness   (also  in 
cephalhematoma) . 

Treatment.  Light  compression  by  bandages 
soon  causes  resorption  of  the  effusion.  In  delayed 
resorption  the  fluid  may  he  evacuated  by  puncture. 
If  suppuration  occurs  an  incision  must  be  made. 

Fig.  78  shows  extensive  suggillations  and  suffu- 
sions of  the  skin  of  the  whole  arm,  which  is  colored 
purple,  brownish-red,  green  and  yellow.  The 
presence  of  a  subcutaneous  hematoma  is  shown  by 
swelling  and  fluctuation. 

It  is  a  typical  case  of  gunshot  injury  to  the  soft 
parts,  in  which  the  apertures  of  entry  and  exit  are 
characteristic.  The  aperture  of  entry  is  smaller  than 
that  of  exit  and  shows  radiating  processes  in  the  skin. 
The  skin  is  colored  black  and  contains  granules  of 
powder,  owing  to  the  shot  being  fired  at  close  quarters. 
In  shot  wounds  of  the  face  these  powder  granules 
remain  for  a  long  time  after  the  wound  has  healed, 
and  cause  an  unsightly  appearance.  The  aperture 
of  exit  is  larger  with  irregular  everted  borders.  These 
wounds  are  typical  of  modern  projectiles  with  great 
penetrating  power. 

Septic  infection  does  not  usually  occur  in  gunshot 
wounds,  as  the  bactericidal  power  of  the  organism  is 
sufficient  to  counteract  the  slight  infection  caused  by 
projectiles.  Even  infected  foreign  bodies,  such  as 
shreds  of  cloth,  may  heal  up  in  the  body. 

The  prognosis  of  gunshot  wounds  of  the  soft  parts 
is  good  if  undue  interference  is  avoided.  All  prob- 
ing of  the  wound  and  search  for  the  bullet  is  to  be 
condemned,  as  it  generally  sets  up  virulent  infection 
of  the  wound.  Disinfection  of  the  wound  is  also 
unnecessar}\  The  best  treatment  is  to  apply  an 
antiseptic  sterilized  gauze  dressing  (iodoform  gauze 
if  there  is  much  bleeding)  and  keep  the  part  at  rest; 
in  the  extremities  by  the  aid  of  plaster  of  Paris.     By 

161 


this  simple  treatment,  first  introduced  by  von  Berg- 
viann,  the  best  results  are  obtained,  not  only  in  gun- 
shot wounds  of  the  soft  parts,  but  also  in  wounds  of 
the  joints  and  bones,  even  comminuted  fractures. 

In  gunshot  injuries  of  large  blood-vessels  opera- 
tive interference  is  necessary;  e.g.  ligation  of  the 
middle  meningeal  artery. 

If  the  wound  becomes  infected,  as  often  happens 
after  injuries  with  explosive  bullets  (dum-dum  bul- 
lets, etc.),  a  free  incision  must  be  made  to  give  outlet 
to  the  pus.  Bullets  and  pieces  of  clothing  which 
have  become  healed  over  may  give  rise  to  abeess 
after  some  years. 

As  a  rule  bullets  should  be  left  alone ;  a  bullet  has 
even  remained  in  the  apex  of  the  heart  without  caus- 
ing trouble  {Trendelenburg) .  Only  superficially  situ- 
ated bullets  should  be  removed,  after  locating  them 
by  means  of  the  X-rays.  Bullets  in  the  frontal  or 
maxillary  sinuses,  or  in  the  mastoid  process  should 
be  removed,  as  they  give  rise  to  pain  and  chronic 
catarrh.  Bullets  should  also  be  removed  which 
cause  pressure  on  tendons  and  nerves,  or  are  situated 
in  the  phalanges,  or  prevent  union  of  fractures. 

Blank  cartridges,  in  which  tetanus  spores  are  often 
present,  should  be  removed  on  account  of  the  danger 
of  tetanus.  In  war,  there  is  always  a  danger  of 
tetanus  infection  of  every  large  bullet  wound,  from 
the  presence  of  tetanus  bacilli  in  the  ground  on  which 
the  wounded  lie.  As  the  treatment  of  antitoxin  is 
only  efficacious  before  the  tetanus  appears  and  is  too 
complicated  to  be  used  in  warfare,  the  author  recom- 
mends, on  the  strength  of  experimental  research,  the 
application  of  fat  to  wounds  suspected  of  tetanus 
infection,  as  fatty  substances  attenuate  the  tetanus 
toxin  (Surgical  Congress,  1907  Bockenheimer's  anti- 
tetanus ointment). 

The  search  for  deep-seated  bullets  in  the  brain 
causes  much  injury.  Accumulation  of  blood  or  cere- 
brospinal fluid,  may  abolish  the  reflexes  for  a  time, 

162 


and  paralysis  may  appear,  but  in  spite  of  this  recovery 
may  take  place  after  a  time. 

Bullets  situated  outside  the  cortex  of  the  brain 
must  be  removed  when  convulsions  occur  from  pres- 
sure of  the  bullet,  or  a  splinter  of  bone,  or  an  accu- 
mulation of  blood  or  pus. 

Effusion  of  blood  in  the  thorax  through  wound  of 
the  lung  should  be  left  to  be  resorbed.  If  it  becomes 
so  extensive  as  to  displace  the  heart  puncture  must 
be  performed,  and  if  suppuration  occurs  resection  of 
the  ribs. 

In  gunshot  wounds  of  the  heart,  free  exposure  of 
the  organ  may  be  performed  in  some  cases. 

Gunshot  wounds  of  the  abdomen  require  laparot- 
omy at  the  earliest  possible  opportunity. 

In  wounds  of  the  larj-nx  immediate  tracheotomy  is 
necessary  to  avoid  death  from  asphyxia. 

In  the  above-mentioned  cases  resorption  of  the 
blood  effusion  and  healing  of  the  wounds  takes  place 
in  a  few  weeks  under  the  application  of  fixed  aseptic 
dressings. 


163 


PETECHLS  ET  affiMORRHAGLffi)  PER  COMPRESSIONEM 

{Petechia  and  Hemorrhage  from  Compression) 
Plate  LXI,  Fig.  79. 

Punctiform  and  striate  hemorrhages  in  the  skin  in 
the  form  of  petechise  and  ecchymoses,  and  diffuse 
cutaneous  extravasations  of  blood  are  included  in 
the  term  congestive  hemorrhages.  These  appear  in 
the  head  and  neck;  hemorrhage  from  compression 
of  the  lower  parts  of  the  body  generally  occurs  in  the 
thorax.  Sometimes  subconjunctival  effusion  of 
blood  occurs  after  abdominal  compression — an  im- 
portant point  in  criminal  and  accident  cases  in  which 
there  is  no  visible  lesion  of  the  abdomen.  The  sud- 
den appearance  of  this  extensive  hemorrhage  in  the 
head  and  neck  causes  a  dark-blue  coloration  of  the 
skin,  protrusion  of  the  eyes,  and  a  swollen  and 
bloated  appearance  of  the  skin  and  mucous  mem- 
branes. It  occurs  in  cases  of  crush,  run-over  cases, 
and  compression  by  machinery,  and  is  due  to  back 
pressure  on  the  valveless  veins  of  the  neck  from  com- 
pression of  the  thorax  and  abdomen,  with  rupture  of 
the  veins  and  infiltration  of  blood  into  the  tissues. 
There  is  no  hemorrhage  into  the  brain  or  its  mem- 
branes. The  fundus  oculi  is  normal,  as  the  intra- 
ocular pressure  prevents  extravasation  of  blood  from 
the  retinal  vessels. 

The  diagnosis  is  easy,  and  treatment  consists  only 
in  rest  in  bed. 

Fig.  79  shows  a  case  of  congestive  hemorrhage  due 
to  compression  of  the  thorax  in  a  rolling  mill.  The 
whole  face  was  colored  dark  purple  and  the  mucous 
membranes  of  the  lips  and  nostrils  were  swollen. 

164 


Bockenheimer,  Atlas. 


big.  7Q.    Petecliiae  et  Haemorrliagiae  per  comprcssionem. 


Rcbman  Company,  New-York. 


There  was  also  subconjunctival  effusion  of  blood. 
In  the  neck,  the  continuous  purple  coloration  of  the 
face  was  replaced  by  a  brighter  red  coloration  in  the 
form  of  stripes  (petechiie  and  ecchymoses).  The 
petechise  were  situated  over  the  shoulder  and  the 
upper  part  of  the  back;  also  in  the  auditory  canal 
and  the  tympanic  membrane.  No  visible  lesion  was 
present.  The  swelling  of  the  face  disappeared  in  a 
few  days,  and  the  purple  coloration  subsided  in  the 
course  of  time  without  any  treatment.  The  discol- 
oration remained  longest  in  the  eyelids  and  con- 
junctiva. 


165 


HEMANGIOMA  CAVERNOSUM  SUBCUTAmEUM 

{Subcutaneous  Cavernous  Hemangioma) 
Plate  LXn.  Fig.  80. 

Fig.  80  shows  a  subcutaneous  cavernous  heman- 
gioma, which  often  occurs  in  the  region  of  the  rectus 
abdominis  muscle,  sometimes  in  the  muscle  itself. 
Mention  has  already  been  made  of  cavernoma  in 
Plate  XXVII.  They  occur  most  frequently  in  the 
skin  and  subcutaneous  tissue,  where  their  purple 
color  and  lobulated  surface  has  somewhat  the  appear- 
ance of  a  mulberry.  They  are  often  combined  with 
simple  hemangioma  or  with  telangiectases,  and  often 
appear  soon  after  birth.  In  cutaneous  hemangioma 
the  skin  is  much  thinned  and  appears  lobulated  and 
of  a  bluish-black  color.  In  subcutaneous  heman- 
gioma the  skin  may  be  unaltered  at  first,  or  slightly 
irregular  and  marked  by  telangiectases.  Afterwards 
the  skin  becomes  thinned  or  destroyed  by  pressure  of 
the  subcutaneous  growth,  and  assumes  various  colors 
(Fig.  80).  In  the  case  represented  in  the  figure  the 
skin  is  already  destroyed  over  the  blue  parts  of  the 
growth,  and  is  of  a  livid  color  at  the  peripherj'.  The 
growth  is  encapsuled  and  freely  movable  over 
the  abdominal  fascia  (in  distinction  to  infiltrating 
cavernoma).  In  some  parts  the  cavernous  spaces 
can  be  seen  through  the  surface.  In  the  center  of  the 
growth  the  skin  is  yellow  in  some  parts  and  brown  in 
others.  The  growth  was  soft,  elastic  and  com- 
pressible; in  some  places  there  was  thrombosis  with 
consequent  shrinking.  The  growth  had  remained 
stationary  for  a  year. 

Subcutaneous    cavernomas    of    the    scalp    require 
special  mention,  as  they  may  communicate  with  a 

166 


Bockenheimer,  Atlas. 


lab.  LXII 


Fig.  80.    Haemangioma  cavernosum  subcutaneum. 


Rebman  Company,  New- York. 


sinus  through  the  emissary  vessels,  without  the  scalp 
showing  much  change. 

For  Differential   Diagnosis  and  Treatment 

see  Plate  XXVII,  Fig.  3(i. 

On  account  of  the  danger  of  rupture  and  hemor- 
rhage, the  case  in  Fig.  80  was  extirpated  and  the 
wound  closed  by  suture.  Recurrence  sometimes 
occurs  after  total  extirpation. 


167 


HEMANGIOMA  CUTANEDM  ET  SUBCUTAWEUM 

(Subcutaneous  and  Cutaneous  Hemangioma) 
TELEANGIEKTASIAE  {Teleangiectases) 

Plate  LXIII,  Fig.  81. 

Fis.  81  shows  a  combination  of  cutaneous  and  sub- 
cutaneous  hemangiomas  with  telangiectases,  affect- 
ing the  leg.  The  telangiectases  are  seen  as  red  spots, 
in  some  places  arranged  in  the  form  of  a  wreath. 
There  is  also  an  extensive  subcutaneous  heman- 
gioma, of  a  bluish-red  color,  with  more  or  less  nor- 
mally colored  skin  in  the  central  parts.  These 
growths  may  remain  covered  by  intact  skin  for  a 
long  time,  while  the  growth  seen  through  it  gives  it  a 
bluish  coloration.  In  this  case,  at  the  lower  part  of 
the  subcutaneous  hemangioma,  there  were  cutaneous 
hemangiomas  in  the  form  of  more  elevated,  round  for- 
mations in  the  skin,  resembling  the  simple  cutaneous 
hemangioma  represented  in  Fig.  75.  In  the  whole 
region  of  the  subcutaneous  hemangioma  fine  ramify- 
ing blood-vessels  can  be  seen.  In  the  face,  combina- 
tions of  cutaneous  and  subcutaneous  hemangiomas 
sometimes  form  a  characteristic  appearance,  the  sub- 
cutaneous growth  giving  a  blue  color  to  the  skin, 
while  the  cutaneous  angioma  appears  in  the  form  of 
lobulated  growths  or  of  bluish-red  nodules  projecting 
from  the  surface.  In  Fig.  81  the  difference  in  color 
between  the  cutaneous  and  the  subcutaneous  heman- 
giomas is  very  marked,  the  former  being  red,  the 
latter  bluish  in  color.  A  combination  of  sub- 
cutaneous with  cutaneous  hemangioma  and  telangi- 
ectases is  not  very  rare.  The  cutaneous  heman- 
gioma sometimes  develops  when  the  subcutaneous 
growth  appears  under  the  skin. 

For  Differential   Diagnosis  and  Treatment 

see  Fig.  75. 

168 


Bockenheimer,  Atlas. 


Tab.  LXIII. 


Fiy.  81.    Hamangioma  cutaiieiim  et  subcutancum  —  Tclcangiektasiae. 


Rebman  Comnanv.  Kpw.VnrV 


Tab.  LXIV. 


Fig.  82.    Aiieurysiiia  arteriale. 


ANEURISMA  ARTERIALE  (Arterial  Aneurism) 
Plate  LXIV.  Fig.  8i. 

An  aneurism  is  a  partial  dilatation  of  an  artery. 
The  term  true  aneurism  is  applied  to  those  dilatations 
which  are  formed  by  all  the  three  coats  of  the  artery. 
Through  wearing  away  of  the  arterial  wall,  the  blood 
escapes  from  the  vessel  and  is  enclosed  by  the  neigh- 
boring soft  parts,  forming  a  false  aneurism.  A  form 
of  false  aneurism  has  already  been  mentioned  as 
pulsating  hematoma  (Fig.  78) ;  in  this  case  there  is 
a  subcutaneous  injury  to  large  blood-vessels. 

In  both  true  and  false  aneurism  we  distinguish  a 
circumscribed  and  a  diffuse  form,  but  the  classifica- 
tion of  aneurisms  into  cylindrical,  saccular  and  fusi- 
form is  of  no  importance,  and  only  has  a  clinical 
interest  in  cirsoid  aneurisms  (Fig.  75). 

True  aneurisms  are  caused  by  disease  of  the 
arterial  walls  from  infective  diseases,  chiefly  syphilis. 
When  the  morbid  processes  extend  over  large  areas 
of  the  arterial  system  the  aneurisms  may  be  multiple. 
These  occur  especially  in  the  small  arteries  of  the 
brain,  sometimes  also  in  the  lungs,  and  by  their  rup- 
ture give  rise  to  multiple  apoplexy.  This  occurs 
chiefly  in  syphilitic  disease  of  the  arteries,  and  in  the 
arteriosclerosis  of  young  people. 

True  aneurisms  are  often  situated  in  the  ascending 
aorta  (syphilis),  also  in  places  where  the  arteries  are 
liable  to  traction  or  pressure  from  flexion  of  the 
extremities:  e.g.  aneurism  of  the  femoral  artery  from 
pressure  of  an  osseous  growth  ("rider's  bone")  in 
the  adductor  muscle;  aneurism  at  the  entrance  of 
the  femoral  artery  in  Hunter's  canal;  popliteal 
aneurism,  etc. 

169 


False  aneurisms  may  arise  from  true  aneurisms 
(consecutive  false  aneurism),  or  from  injury  to  an 
artery,  causing  pulsating  hematoma  (traumatic  false 
aneurism).  Aneurisms  only  attain  large  dimensions 
when  they  are  surrounded  by  soft  tissues  (skin,  muscle, 
and  fat).  They  are  at  first  diffuse  and  ill-defined, 
but  eventually  become  circumscribed  swellings,  owing 
to  the  formation  of  a  connective-tissue  capsule  from 
the  surrounding  tissues. 

If  both  arterj'  and  vein  are  injured,  which  happens 
in  the  majority  of  cases,  an  arterio-venou^  aneurism 
is  produced.  This  is  called  aneurismal  varix  when 
there  is  direct  communication  between  the  artery  and 
vein,  and  a  varicose  swelling  of  the  latter;  varicose 
aneurism  when  the  two  vessels  communicate  through 
a  sac  which  is  formed  between  them.  However,  this 
distinction  is  not  always  evident  clinically,  especially 
when  a  series  of  inextricable  sacs  and  communica- 
tions is  formed  through  multiple  perforations  of  the 
artery  and  vein.  Traumatic  aneurisms,  both  arte- 
rial and  arterio-venous,  were  formerly  common  in 
the  bend  of  the  elbow  as  the  result  of  phlebotomy. 
They  generally  arise  from  punctured  wounds,  or 
gunshot  wounds  with  modern  bullets. 

Clinically,  both  true  and  false  aneurisms  are  of 
gradual  development,  as  in  traumatic  aneurism  there 
is  also  a  long  interval  before  the  sac  is  formed.  The 
sac  may  attain  the  size  of  a  man's  head,  forming  a 
visibly  pulsating  swelling,  the  pulsation  ceasing  after 
compression  of  the  artery  on  the  side  next  the  heart. 
The  pulsation  may  be  absent  when  the  sac  wall  has 
become  thickened  by  thrombosis.  The  swelling  can 
be  diminished  by  pressure.  On  auscultation  of  the  sac 
a  bruit  is  heard,  which  is  synclironous  with  systole  of 
the  heart  in  arterial  aneurism;  irregular  during  both 
systole  and  diastole,  in  arterio-venous  aneurism.  In 
the  latter  condition  there  is  congestion  in  the  region 
of  the  vein,  with  consecutive  disturbance  of  nutrition, 
eczema,  ulcers,  and  abscess  formation. 

170 


Aneurisms  as  a  rule  have  a  slow  but  persistent 
growth,  and  tend  to  eventual  rupture.  In  arterial 
aneurism  a  cure  sometimes  occurs  from  thrombosis. 

Aneurisms  often  cause  severe  symptoms  from 
pressure  on  the  neighboring  organs;  e.g.  paraesthe- 
sias,  neuralgia  and  paralysis  from  pressure  on  the 
ner\-es;  congestion  and  elephantiasis  from  pressure 
on  the  veins.  A  large  aneurism  may  cause  atrophy 
of  the  bones  from  pressure   (sternum  and  vertebrae). 

Differential  Diagnosis.  True  aneurisms  can  be 
distinguished  from  false  traumatic  aneurisms  by  care- 
ful examination.  Abscesses,  or  benign  and  malig- 
nant tumors,  especially  sarcoma,  when  they  receive 
pulsation  from  an  underlying  vessel,  may  be  mis- 
taken for  aneurism.  Aneurisms  in  which  there  is  no 
pulsation  or  bruit,  owing  to  thickening  of  their  walls 
from  thrombosis,  and  which  have  caused  inflamma- 
tory changes  in  the  skin  by  pressure,  may  be  mistaken 
for  abscesses  and  be  incised. 

In  cavernoma  there  is  dilatation  of  the  vessels  but 
no  pulsation.  Racemose  aneurism  presents  itself  as 
an  irregular  serpentine  arterial  swelling  caused  by 
the  tortuous  dilatation  of  a  vascular  area. 

In  many  cases  the  X-rays  are  useful  in  the  diag- 
nosis of  aneurism,  which  gives  a  dark  shadow  in  the 
X-ray  picture. 

The  prognosis  of  aneurism  is  always  unfavorable. 

Treatment.  For  large  spontaneous  subcutaneous 
aneurisms,  the  injection  of  coagulating  fluids  has  been 
recommended,  but  these  are  not  free  from  danger. 
The  best  is  injection  of  solution  of  gelatin  into  the 
sac.  Other  methods,  which  also  aim  at  coagulation, 
are  the  introduction  of  needles  or  magnesium  into  the 
sac,  and  electropuncture.  In  the  extremities,  digital 
compression  or  compression  by  instruments  generally 
causes  only  temporary  improvement.  Compression 
of  the  common  carotid  artery  and  the  internal  carotid 

1:1 


are  not  without  danger,  as  they  may  cause  convul- 
sions and  unconsciousness. 

The  most  certain  method  is  ligation  of  the  vessel 
above  and  below  the  sac  and  removal  of  the  sac. 

In  arterio-venous  aneurism  all  the  sacs  must  be 
removed  after  ligation  of  all  the  vessels  connected 
with  them.  Ligation  of  the  common  carotid,  which 
may  lead  to  softening  of  the  brain,  may  be  performed 
if  a  temporary  ligature  of  the  carotid  is  well  borne. 

The  ideal  method  is  extirpation  of  the  aneurism 
with  restoration  of  the  blood-stream  by  suture  of  the 
vessel  {Paijr)  with  the  aid  of  prothesis,  which  avoids 
such  complications  as  softening  of  the  brain  and  gan- 
grene of  the  extremities  after  ligation  of  the  main  ves- 
sel. Lexer  recommends  lateral  suture  of  the  vessels, 
circular  suture,  or  transplantation  of  vessels. 

In  some  cases  peripheral  ligation  only  is  possible; 
e.g.  in  aneurism  of  the  subclavian  artery.  In  the 
extremities,  when  there  is  much  disturbance  of  nutri- 
tion, the  question  of  amputation  arises. 

Internal  medication  consists  in  the  administration 
of  iodide  of  potassium,  with  a  view  to  the  syphilitic 
origin  of  aneurism. 


'&' 


Fig.  82  shows  a  visibly  pulsating  swelling  in  the 
region  of  the  sterno-clavicular  joint  in  a  middle-aged 
man  with  a  probable  history  of  syphilis.  It  consists 
in  a  circumscribed  arterial  aneurism,  and  presented 
all  the  clinical  symptoms  of  arterial  aneurism— pul- 
sation, diminution  on  pressure,  systolic  bruit  and 
buzzing  over  the  swelling.  The  swelling  increased 
in  size  slowly  but  continually,  and  was  shown  by  the 
X-rays  to  be  an  aneurism  of  the  aorta.  There  was 
paralysis  of  the  left  recurrent  laryngeal  nerve  from 
pressure  of  the  dilated  aortic  arch,  a  characteristic 
symptom  of  aortic  aneurism,  which  sometimes  mani- 
fests itself  by  hoarseness ;  but,  when  there  is  compen- 
sation of  the  paralysis,  it  can  only  be  recognized  by 
laryngoscopic  examination.     An  early  symptom  of 

172 


aortic  aneurism  is  also  the  phenomenon  first  described 
by  Oilier — pulsation  of  the  larynx.  When  the  larynx 
is  pulled  upwards  there  is  a  sensation  of  traction  from 
below  ("tracheal  tugging"). 

In  this  case,  pressure  on  the  brachial  plexus  caused 
parsesthesias  in  the  right  arm;  pressure  on  the  veins 
caused  cyanosis  of  the  face  and  neck;  while  the  dys- 
phagia from  pressure  on  the  esophagus,  and  dysp- 
noea, which  frequently  occur  in  such  aneurisms, 
were  absent. 

Non-pulsating  aneurisms  may  be  mistaken  for 
gumma,  which  is  common  in  this  situation.  Aneu- 
risms of  the  aorta  are  often  unrecognized  till  they 
rupture,  an  event  which  may  occur  after  sounding  a 
stricture  of  the  esophagus  caused  by  the  aneurism 
itself. 


173 


VARK  CmSOIDES— PES  VALGUS  (Cirsoid  Varix—Fhi  Foot) 
Plate  LXV,  Fig.  S3. 

The  term  phlebectasis  is  applied  to  dilatations  and 
tortuosities  of  veins.  They  may  occur  in  various 
parts  of  the  body;  e.g.  in  the  inferior  hemorrhoidal 
plexus  of  veins,  as  hemorrhoids;  in  the  pampiniform 
plexus,  as  varicocele  (this  is  more  common  on  the 
left  side  owing  to  the  fact  that  the  left  spermatic  vein 
opens  at  right  angles  into  the  renal  vein  and  is  thereby 
more  liable  to  backward  pressure  and  congestion); 
more  commonly  in  the  veins  of  the  leg  (large  and 
small  saphenous  veins),  where  they  are  known  as 
varicose  veins  or  varix. 

Phlebectases  appear  as  multiform  tortuous  blue 
cords  (cirsoid  varix)  clearly  visible  under  the  thinned 
skin,  on  the  inner  side  of  the  leg  in  the  region  of  the 
large  saphenous  vein.  Varices  of  the  small  saph- 
enous vein  on  the  outer  side  of  the  leg  and  calf  are 
less  common. 

Nodular  swellings  occur  in  places  where  the  veins 
have  valves. 

In  the  upper  extremity  phlebectasis  is  less  often 
observed,  but  may  occur  in  connection  with  tumors 
of  the  neck  and  shoulder.  Phlebectases  on  the  abdo- 
men (called  caput  medusae)  are  due  to  obstruction  of 
the  portal  circulation.  Submucous  varices  occur  in 
the  esophagus  and  alimentary  canal.  Varicose  veins 
also  occur  in  the  brain,  especially  in  the  Sylvian 
fissure. 

Phlebectases  in  the  legs  are  usually  due  to  disturb- 
ance in  the  circulation;  e.g.  from  the  pressure  of 
pelvic  tumors.     Phlebectases  may  occur  on  both  sides 

174 


Bockenheiiiicr,  Atlas. 


Tab.  I.XV. 


Fig.  83.    V'aiix  cirsoides  —  Pes  valgus. 


Rcbm.Tii  Company,  New-York. 


and   be   combined   with   hemorrhoids,   especially   in 
women  who  have  had  many  pregnancies. 

Under  the  thinned  skin  hard  lumps  can  be  felt 
where  thrombosis  has  occurred.  Sometimes  the 
thrombi  are  calcified,  and  are  then  known  as  phlebo- 
liths.  At  the  commencement  of  the  affection,  before 
the  varices  become  prominent,  fine  ramifying  vessels 
are  found  under  the  skin,  which  later  on  appear 
between  the  veins.  These  ramifying  vessels  give  the 
skin  a  brownish  appearance. 

Varices  which  extend  in  the  form  of  ramifying 
anastomoses  and  networks  over  the  whole  leg  are 
connected  both  with  the  skin  and  subcutaneous 
tissue,  and  become  very  extensive  when  the  valves  of 
the  large  saphenous  vein  are  destroyed,  thus  imped- 
ing the  circulation.  The  insufficiency  of  the  valves 
can  be  shown  by  raising  the  limb  till  the  varices  have 
emptied  themselves  of  blood;  then  compress  the 
saphenous  vein  at  its  opening  into  the  femoral  vein 
in  the  thigh,  lower  the  limb  and  suddenly  remove 
pressure  on  the  saphenous  vein;  the  varices  then 
become  again  filled  with  blood  from  the  femoral  vein. 

The  patients  suffer  more  when  standing  than  when 
walking.  The  chief  symptoms  are  tingling  and 
numbness  in  the  limb,  cramps  in  the  calves,  especially 
when  the  deeper  veins  are  affected,  swelling  of  the 
feet,  eczema,  ulceration  and  even  elephantiasis. 
These  troubles  often  cause  much  suffering. 

Varices  may  be  dangerous  from  rupture  and 
hemorrhage.  As  a  rule  the  small,  thin,  ramifying 
peripheral  vessels  rupture,  sometimes  the  larger 
trunks.  The  blood  being  under  considerable  pres- 
sure spurts  out  in  a  jet.  Fatal  hemorrhage  may  take 
place  unless  the  limb  is  elevated  and  the  bleeding 
stopped  by  pressure.  Death  may  occur  in  rupture  of 
subcutaneous  varices  in  the  leg  and  in  the  internal 
organs  {e.g.  brain  and  liver).  The  second  danger 
is  thrombo-phlebitis  which  may  lead  to  embolism, 
especially  when  it  becomes  purulent  (Fig.  84). 

1(5 


Differential  Diagnosis.  Varicose  veins  are  so 
typical  in  appearance  that  they  cannot  be  mistaken 
for  the  vascular  formations,  such  as  aneurism,  cir- 
soid aneurism  or  cavernoma.  Primary  phlebectasis 
must  not  be  confounded  with  the  dilatation  of  super- 
ficial veins  caused  by  thrombosis  of  the  deeper  veins; 
e.g.  after  infective  diseases. 

Treatment.  Prophylactic  treatment  consists  in 
avoiding  long  standing,  in  cleanliness  and  massage. 
In  slight  cases  the  circulation  of  the  limb  can  be  im- 
proved by  the  application  of  flannel  bandages  from 
the  toes  upwards  {Martin's  rubber  bandage  is  liable 
to  cause  eczema).  If  the  varix  is  caused  by  pressure 
of  a  tumor,  this  must  be  removed  when  possible. 

The  most  radical  treatment  consists  in  extirpation 
of  the  varices,  especially  w-hen  very  tortuous.  If  the 
valves  of  the  vein  are  destroyed  (shown  by  the  method 
mentioned  above),  it  is  best  to  ligature  the  saphenous 
vein  near  its  opening  into  the  femoral  vein,  and  to 
resect  a  part  of  it  as  well.  After  the  operation  small 
varices  and  eczema  quickly  disappear,  but  elastic 
bandages  should  be  worn  for  some  time.  The  extir- 
pation of  secondary  varices  due  to  thrombosis  of  the 
deeper  veins  is  useless. 

Varicocele  should  be  excised  in  its  whole  extent; 
the  testicle  can  be  drawn  up  by  suture. 

Submucous  varices  of  the  esophagus  and  varices 
in  the  brain  and  liver  are  inaccessible  to  treatment. 

Fig.  83  shows  somewhat  extensive  varices  in  the 
region  of  the  large  saphenous  vein  in  the  leg,  in  a 
woman  of  forty,  after  many  pregnancies.  The  above- 
mentioned  ramifying  vessels  are  seen  between  the 
varices,  giving  the  skin  a  reddish-brown  appearance. 

In  this  case  the  foot  was  in  a  position  of  pronation 
and  abduction  (pes  valgus  or  flat-foot) 


176 


PES  VALGUS  OR  FLAT-FOOT 

The  treatment  of  pes  valgus  depends  on  its  cause. 
The  deformity  may  be  congenital  or  acquired  (trau- 
matic, paralytic,  rickety  (Fig.  65),  or  due  to  long 
standing). 

In  all  these  forms  the  foot  is  more  or  less  in  a  posi- 
tion of  pronation  and  abduction,  and  eventually  there 
is  displacement  at  the  astragalo-scaphoid  articula- 
tion. Along  with  changes  in  the  bones  and  destruc- 
tion of  cartilage  in  the  joints,  the  ligaments,  tendons 
and  muscles  are  also  affected. 

Traumatic  flat-foot  occurs  not  only  after  fractures 
of  the  leg  and  ankle,  but  also  as  the  result  of  rupture 
of  the  ligaments  from  twisting  of  the  foot,  especially 
when  the  injury  is  not  treated  by  fixation.  Paralytic 
flat-foot  occurs  after  acute  anterior  poliomyelitis,  in 
which  the  plantar  flexors  are  paralyzed  and  there  is 
over-action  of  the  extensors. 

Rickety  flat-foot  is  due  to  sinking  of  the  arch  of 
the  foot  owing  to  softness  of  the  bones. 

The  commonest  form  is  static  flat-foot,  which 
occurs  in  persons  of  weak  muscular  power,  as  the 
result  of  prolonged  standing  (waiters,  etc.).  It  gen- 
erally develops  at  the  age  of  puberty.  The  symp- 
toms are  fatigue,  pains  in  the  ankle  and  tarsal  joints, 
and  on  the  outer  side  of  the  leg.  The  pains  are  often 
cramp-like  (tarsalgia). 

Differential  Diagnosis.  Pes  valgus  must  not  be 
confounded  with  the  flat-foot  which  occurs  in  certain 
races  (Jews,  negroes).  The  latter  is  due  to  imperfect 
development  of  the  arch  of  the  foot,  but  there  are  no 


changes  in  the  mid-tarsal  joint,  and  the  condition 
causes  little  trouble. 

Treatment.  In  congenital  flat-foot  the  position 
can  be  corrected  by  manipulation  and  massage.  In 
traumatic  flat-foot  caused  by  fractures  and  sprains, 
the  patients  should  not  walk  too  soon,  and  then  only 
with  a  well-made  boot  provided  with  a  flat-foot  sole. 
In  more  severe  degrees  of  traumatic  flat-foot,  the 
question  of  cuneiform  osteotomy  of  the  scaphoid 
bone  or  head  of  the  astragalus,  or  linear  osteotomy 
of  the  tibia  and  fibula  may  arise.  These  operations 
may  be  considered  in  cases  where  manipulation  has 
failed  to  correct  the  position.  If  the  tendon  Achilles 
is  much  shortened  it  should  be  tenotomized  before 
manipulation.  After  manipulation  the  foot  should 
be  put  up  in  plaster  of  Paris  in  an  over-corrected 
position. 

In  paralytic  flat-foot  tendon-transplantation  is  use- 
ful. The  peripheral  end  of  the  divided  tendon  of  the 
paralyzed  tibialis  anticus  muscle  can  be  connected 
with  the  tendon  of  the  healthy  extensor  longus  hallucis 
muscle. 

Inflammatory  flat-foot,  which  causes  painful  con- 
tracture, should  be  treated  by  rest  in  bed  and  hot 
fomentations.  If  the  pain  is  very  severe  cocaine  may 
be  injected. 

General  treatment  consists  in  strengthening  the 
muscles  (tibialis  anticus  and  posticus,  and  calf  mus- 
cles) ;  active  movements  and  massage.  When  stand- 
ing the  toes  should  be  turned  inwards,  and  when 
walking  the  foot  should  not  be  turned  outwards. 
The  boots  should  be  well-made  with  flat-foot  pads; 
the  latter  are  made  after  an  impression  of  the  foot 
taken  on  smoked  paper,  and  should  extend  from  heel 
to  toes  over  the  whole  sole. 


178 


PYOGENIC  mPECTIONS 
Plate  LXVI  et  seq. 

The  bacterial  invasion  of  injured  or  uninjured 
parts  of  the  body  plays  a  great  part  in  surgery,  as 
there  is  always  the  possibility  of  bacterial  infection 
in  every  injury  and  operation. 

According  to  the  nature  of  the  infection,  definite 
clinical  pictures  are  produced  which  are  generally 
represented  by  various  degrees  of  inflammation  and 
reaction  of  the  body.  These  processes  may  be 
mcited  not  only  by  bacterial  irritation  but  by  mechan- 
ical irritation,  such  as  trauma  without  infection,  also 
by  chemical  irritation  (e.g.  poisons  of  all  kinds, 
animal  poisons  such  as  snake  poison),  and  by  the 
action  of  heat  and  cold  (burns  and  freezing). 

In  bacterial  infection  the  inflammation  is  most 
marked,  as  it  does  not  remain  limited  to  the  place  of 
origin,  but  extends  more  or  less  rapidly  in  the  sur- 
rounding parts,  and  may  eventually  reach  remote 
parts  of  the  body  by  way  of  the  blood  and  lymphatic 
vessels  (general  infection).  According  to  the  rate  of 
its  extension,  the  inflammation  may  be  acute,  chronic 
or  subacute.  All  three  forms  may  pass  into  each 
other. 

Bacterial  infection  causes  various  clinical  phe- 
nomena according  to  the  nature,  number  and  viru- 
lence of  the  bacteria,  and  according  to  the  parts  of 
the  organism  which  are  invaded,  and  the  power  of 
resistance  of  the  individual.  Old,  feeble  and  dis- 
eased bodies  (e.g.  diabetes)  are  less  capable  of  com- 
bating bacterial  invasion,  while  a  healthy  body 
shows  a  strong  reaction  against  it.     This  reaction 

179 


manifests  itself  by  inflammation  at  the  point  of 
infection. 

This  inflammatory  reaction  is  manifested  by  the 
cardinal  symptoms — redness,  heat,  swelling  and 
pain.  The  redness  and  heat  are  due  to  dilatation  of 
the  blood-vessels  from  irritation  of  the  tissues  (active 
or  arterial  hypera?mia);  the  swelling  and  pain  are 
due  to  the  transmigration  of  blood  elements,  espe- 
cially leucocytes,  owing  to  the  slowing  of  the  blood 
stream.  In  every  severe  infection  the  function  of  the 
part  concerned  is  also  interfered  with. 

The  exudation  varies  in  degree  according  to  the 
nature  of  the  infection.  It  may  be  serous,  fibrinous, 
sero-fibrinous,  or  purulent;  and  when  mixed  with 
red  blood  corpuscles  becomes  hemorrhagic.  Puru- 
lent exudation  is  the  most  common,  and  recurs  in  its 
simplest  form  in  wounds  which  do  not  heal  by  pri- 
mary union. 

Pyogenic  infections  are  also  distinguished  accord- 
ing to  their  situation  and  extent.  They  may  thus  be 
superficial  or  deep;  circumscribed  or  diffuse;  cuta- 
neous, subcutaneous,  muscular,  glandular,  or  osse- 
ous, etc. 

Besides  the  local  inflammatory  reaction  of  the  part 
of  the  body  attacked,  there  is  a  general  reaction 
shown  by  considerable  and  prolonged  rise  of  tempera- 
ture. This  must  be  distinguished  from  the  slighter 
degree  of  so-called  aseptic  fever  which  occurs  during 
resorption  of  blood  effusions.  The  temperature 
chart  in  pyogenic  infections,  together  with  the  local 
reaction  and  the  general  symptoms  (rigors,  pains  in 
the  joints,  dry  tongue,  sweating,  diarrhea  and  vom- 
iting) are  of  the  greatest  importance  in  estimating 
the  degree  of  wound  infection. 

After  the  first  stage  of  inflammation,  which  causes 
more  or  less  destruction  of  tissue,  comes  the  stage  of 


regeneration. 


Owing  to  the  formation  of  granulation  tissue  from 
the  fixed  connective  tissue  cells  the   inflammatory 

180 


area  becomes  isolated  and  demarcated,  the  necrosed 
tissue  becomes  separated  and  is  discharged  with  the 
pus,  and  the  wound  eventually  heals  by  scar  tissue 
which  is  developed  from  the  vascular  granulations. 
As  the  stage  of  reparation  proceeds,  the  clinical 
symptoms  of  inflammation  subside. 

If  the  infection  is  very  virulent,  the  body  cannot 
overcome  the  bacteria  and  their  products  of  meta- 
bolism. From  the  local  infection  arises  a  general 
infection  which  the  defensive  power  of  the  body  is 
generally  unable  to  combat. 

The  researches  of  Ehrlich  and  Morgenroth  have 
thrown  much  light  on  this  complicated  process. 
This  is  not  sufficiently  explained  by  the  presence  of 
a  substance  (called  alexin)  present  in  ihe  blood- 
serum,  nor  by  Metchnikofj's  theory  o:  phagocytosis 
(destruction  of  bacteria  by  the  white  blood  corpus- 
cles), but  depends  on  the  combined  action  of  several 
factors.  Also,  the  still  more  complicated  processes 
of  the  formation  of  antitoxins,  and  the  immunization 
of  the  organism,  have  been  made  comprehensible  by 
Ehrlich' s  "side-chain"  theory. 

Again,  the  knowledge  of  surgical  infections  due  to 
bacteria  has  been  extended  by  numerous  observers 
{Koch,  Fehleisen,  Rosenbach  and  others).  The  harm- 
ful action  of  bacteria  is  due  to  their  multiplication  in 
the  organism,  and  to  the  formation  of  products  of 
metabolism,  the  most  dangerous  of  which  are  the 
toxalbumins  (or  toxins)  excreted  by  living  bacteria; 
while  the  poisons  found  within  the  bacteria,  which 
lead  to  their  destruction,  are  known  as  endotoxins 
and  are  of  less  importance. 

While  the  normal  skin  and  mucous  membranes  only 
rarely  harbor  bacteria,  every  wound  forms  a  favora- 
ble soil  for  their  development,  and  from  this  they 
spread  by  the  blood  and  lymphatic  vessels.  The 
organism  may  be  infected  by  one  or  several  kinds  of 
bacteria  (mixed  infection). 

The  most  important  bacteria  from  the  surgeon's 

181 


point  of  view  are  those  which  cause  pyogenic  infec- 
tions— the  staphylococcus  aureus  and  albus  and  the 
streptococcus  pyogenes.  Most  acute  inflammatory 
processes,  whether  a  wound  is  present  or  not,  are 
due  to  these  forms  of  bacteria. 

Staphylococcal  infections  are  very  common  (fur- 
uncle, carbuncle,  osteomyelitis,  etc.),  and  generally 
lead  to  circumscribed  purulent  inflammations.  Strep- 
tococcal infections  are  more  diftuse  and  often  cause 
general  infection. 

Both  these  forms  of  bacteria  are  especially  virulent 
when  they  give  rise  to  pyogenic  infection  of  the 
human  body.  Other  bacteria  only  cause  a  slighter 
degree  of  inflammation;  generally  serous  or  sero- 
fibrinous, only  occasionally  purulent  (pneumococcus, 
typhoid  bacillus,  bacterium  coli  commune,  gonococ- 
cus,  bacillus  pyocyaneus,  tubercle  bacillus,  diphtheria 
bacillus). 

Differential  Diagnosis.  Pyogenic  infections 
present  such  characteristic  clinical  symptoms  that  a 
general  diagnosis  is  not  difiicult.  A  stricter  diagnosis 
depends  on  the  history  of  the  case,  the  local  and  gen- 
eral condition  and  bacteriological  examination. 

Prognosis.  With  early  diagnosis  and  appropri- 
ate treatment  the  prognosis  is  favorable  as  regards 
life,  but  doubtful  as  regards  function  in  certain 
regions.  There  is  always  danger  to  life  in  every 
pyogenic  infection,  as  a  circumscribed  inflammatory 
focus  may  become  diffuse  and  set  up  general  infec- 
tion. In  consideration  of  this  fact,  every  apparently 
insignificant  pyogenic  affection  must  be  treated  with 
the  greatest  care. 

Treatment.  In  the  first  place  all  sources  of  irri- 
tation must  be  removed  (foreign  bodies,  stone,  etc.). 
Whenever  signs  of  suppuration  appear,  the  affected 
part  must  be  kept  at  rest;   in  the  extremities  by  sus- 

182 


pension.  When  there  is  inflammatory  infiltration  of 
the  skin  without  any  formation  of  pus,  it  may  be 
smeared  with  ointment;  but  the  apphcation  of  an 
ice-bag  is  injurious,  as  it  delays  the  locahzation  of 
the  process  in  the  form  of  a  circumscribed  collection 
of  pus,  which  is  the  object  desired.  Hot,  moist  fo- 
mentations are  best  avoided,  as  they  favor  the 
growth  of  bacteria.  When  a  circumscribed  collec- 
tion of  pus  has  formed,  it  must  be  evacuated  by  a  free 
incision  (pyogenic  conditions  which  require  earlier 
incision  will  be  mentioned  later).  Small  abscesses 
can  be  opened  under  local  anaesthesia,  but  more 
extensive  ones  require  a  general  aneesthetic.  Local 
anjesthetics  should  never  be  injected  into  inflamma- 
tory tissue,  as  they  are  very  painful  and  may  also 
give  rise  to  general  infection. 

Large  incisions,  made  so  as  to  give  the  best  outlet 
for  the  pus,  lead  to  more  rapid  healing  than  small 
incisions.  The  after-treatment  is  rendered  much 
simpler  by  large  incisions,  while  small  incisions 
often  require  further  incision.  For  the  same  reason, 
evacuation  of  pus  by  an  aspirator  is  more  uncertain 
and  uncleanly. 

After-treatment  consists  in  loosely  plugging  the 
wound  with  dry  iodoform  gauze,  and  later  with 
sterile  gauze,  applied  daily.  Immobilization  should 
be  continued  till  all  signs  of  inflammation  have  sub- 
sided. 

In  cases  where  dry  tampons  cause  pain  they  may 
be  replaced  by  moist  tampons  with  two  per  cent, 
boric  acid  lotion,  one  per  cent,  aluminium  acetate, 
or  three  per  cent,  oxygenated  water,  renewed  two  or 
three  times  a  day.  Tampons  should  not  be  left  in 
too  long,  as  they  cause  irritation  of  the  tissues.  They 
must,  therefore,  be  managed  as  carefully  as  possible, 
if  necessary,  under  an  anaesthetic.  The  application 
of  alcohol,  iodine,  carbolic  acid,  balsam  of  Peru  to 
infected  wounds  (cf.  treatment  of  tetanus.  Fig.  78), 
is  not  to  be  recommended,  as  they  cause  much  irrita- 

183 


tion  in  the  wound.  Von  Bergmann's  method  of  dry 
antiseptic  dressings  is  the  simplest  and  most  practical 
method  of  dealing  with  pyogenic  infections. 

Granulation  tissue  should  be  treated  by  ointments 
of  zinc  oxide  or  nitrate  of  silver,  and  by  baths.  Later 
on,  massage,  active  and  passive  movements  and 
electricity  are  indicated,  according  to  the  situation 
and  nature  of  the  affection.  The  general  condition 
also  requires  treatment  in  every  pyogenic  infection, 
by  tonics  and  nourishing  diet.  When  necessary  sub- 
cutaneous injections  of  normal  saline  solution  and 
nucleinic  acid  should  be  given  (20  cc.  of  nucleinic 
acid  in  200  cc.  of  normal  saline  solution).  Antitoxic 
or  bactericidal  serums  have  so  far  given  no  result  in 
pyogenic  infections. 

The  method  of  passive  hypersemia  advocated  by 
Bier  for  the  treatment  of  acute  pyogenic  infections 
has,  after  the  experimental  and  clinical  research  of 
Lexer,  Wrede,  WoUf-Eisner  and  others,  proved  itself 
to  be  "a  double-edged  sword."  (Discussion  at  the 
Surgical  Congress,  1906).  It  cannot  be  recom- 
mended as  a  practical  method,  as  it  necessitates 
prolonged  internment  of  the  patient  in  hospital.  It 
is  true  that  an  increase  in  the  power  of  defense  takes 
place  at  the  seat  of  infection  after  passive  venous 
hypergemia,  as  it  does  after  active  hypersemia  induced 
by  painting  with  iodine  or  hot-air  treatment.  On 
the  other  hand,  nutrition  is  impaired,  and  the  resorp- 
tion of  the  bacteria  and  their  poisons  delayed  by  the 
venous  hypersemia,  which  may  result  in  further 
destruction  of  tissue  at  the  seat  of  infection.  Again, 
if  the  infection  is  a  virulent  one,  especially  strepto- 
coccal, there  may  be  rapid  resorption  of  bacterial 
poisons  in  the  organisms  after  removal  of  the  elastic 
compression,  which  may  be  fatal.  In  infection  by 
gas-forming  bacteria,  which  may  cause  gangrene  of 
the  tissues  by  pressure  of  gases,  passive  hypersemia 
only  aggravates  this  action. 

We,  therefore,  consider  treatment  by  passive  hyper- 

184 


aemia  (which  cannot  be  endured  by  many  patients) 
as  unnecessary  in  the  milder  forms  of  pyogenic  infec- 
tion. The  above-mentioned  treatment  is  sufficient 
in  these  cases,  especially  when  combined  with  immo- 
bilization. Again,  treatment  by  passive  hypersemia 
often  obscures  the  indications  for  incision.  Small 
incisions  are  often  insufficient  even  in  mild  cases,  and 
require  to  be  enlarged  or  repeated,  thus  complicating 
and  lengthening  the  treatment.  (For  the  treatment 
of  suppuration  in  tendon-sheaths,  see  Fig.  96). 

In  the  more  acute  pyogenic  infections,  which  pre- 
sent severe  clinical  symptoms  and  have  a  tendency 
to  progress,  treatment  by  passive  hypersemia  is 
unsafe,  and  has  often  aggravated  the  condition; 
e.g.,  by  thrombo-phlebitis  of  the  small  veins,  multiple 
abscesses,  and  even  general  infection. 

Finally,  the  treatment  of  acute  pyogenic  infections 
by  passive  hyperaemia  has  not  a  scientific  foundation 
on  bacteriological  research,  nor  is  it  supported  by 
the  results  of  clinical  experience. 


185 


THROMBOPHLEBITIS  ACUTA  PURULENTA 

{Acute  purulent  Thrombo-phlebitis) 
Plate  LXVI,  Fig.  84. 

Acute  purulent  thrombo-phlebitis  may  arise  from 
infection  of  the  neighboring  parts.  In  every  pyogenic 
infection  purulent  thrombi  are  found  in  the  smaller 
veins.  In  the  larger  veins  it  arises  from  periphlebi- 
tis, in  which  there  is  infection  of  the  wall  of  the  vein. 
Infection  of  the  walls  of  veins  may  also  result  from 
internal  infection  by  the  blood.  Purulent  phlebitis 
always  results  in  the  formation  of  a  thrombus  which 
may  cause  complete  occlusion  of  the  vessel.  The 
thrombus  generally  contains  pus  (thrombo-phlebitic 
abscess) ;  it  may  extend  and  infect  larger  areas,  or 
may  disintegrate  and  give  rise  to  general  infection 
by  embolism  (cf.  Fig.  108). 

Various  pyogenic  affections  may  give  rise  to 
thrombo-phlebitis  (lymphangitis,  furuncle,  carbun- 
cle, erysipelas,  varicose  ulcer  of  the  leg).  Otitis 
media  may  cause  thrombo-phlebitis  of  the  lateral 
sinus.  In  the  portal  vein,  infection  by  the  blood 
may  cause  pylephlebitis  and  subsequent  multiple 
abscesses  in  the  liver.  Carbuncle  of  the  lips  may 
cause  meningitis  through  thrombo-phlebitis  of  the 
facial  and  ophthalmic  veins.  When  the  lesion  is 
superficial,  it  gives  rise  to  all  the  symptoms  of  puru- 
lent inflammation — redness,  swelling  and  cedema  of 
the  skin  and  subcutaneous  tissue,  pain,  fever  and 
rigors.  The  skin  is  often  tense  and  hard.  The 
infiltration  extends  along  the  course  of  the  veins,  in 
the  form  of  hard  cords.  The  presence  of  pus  and  the 
formation  of  abscess  is  indicated  by  yellowish  coloring 
of  the  skin  (Fig.  84),  and  later  by  fluctuation. 

186 


HoikenheiiiuT,  Atlas. 


Tab.  I.WI 


Fig.  8-1.     riiioiiibophlebitis  puiulciila  acuta. 


Hebman  tJnnipaiiy,  Nc«-N'nrk. 


Thrombo-plilebitis  of  the  deeper  veins  gives  rise 
to  severe  symptoms — pain,  high  fever,  rigors  and 
change  in  the  general  condition. 

Thrombo-phlebitis  of  the  femoral  vein,  occurring 
in  women  as  the  result  of  puerpural  parametritis,  is 
known  as  phlegmasia  alba  dolens  (white  leg).  In 
this  affection  the  whole  leg  is  affected  by  painful, 
hard  oedema,  preventing  any  movement.  The  throm- 
bosis may  be  so  extensive  as  to  cause  gangrene  of 
the  extremity. 

In  every  case  of  thrombo-phlebitis  the  walls  of  the 
veins  remain  thickened  causing  congestion  which,  in 
the  lower  extremities,  leads  to  deficient  nutrition 
(ulcer,  eczema,  elephantiasis).  Thrombi  may  be- 
come transformed  into  hard,  painful  phleboliths,  by 
deposit  of  calcareous  salts. 

Differential  Diagnosis.  Superficial  thrombo- 
phlebitis differs  from  lymphangitis  in  the  veins  being 
thicker  and  harder.  Deep  thrombo-phlebitis  is  often 
impossible  to  distinguish  from  other  pyogenic  affec- 
tions. 

The  prognosis  is  always  doubtful,  owing  to  the 
possibility  of  general  pyogenic  infection. 

Treatment.  In  the  early  stages  suppuration  of 
the  thrombi  may  be  avoided  by  rest.  In  the  extrem- 
ities, these  should  be  suspended.  The  treatment 
must  be  conducted  according  to  the  general  rules  for 
pyogenic  affections.  Abscesses  must  be  incised; 
there  is  no  fear  of  hemorrhage  owing  to  thrombosis 
of  the  vessels  for  some  distance  from  the  seat  of 
inflammation.  If  general  infection  appears  to  be 
imminent  the  vein  should  be  resected  after  double 
ligation  of  the  diseased  section.  For  example,  liga- 
tion of  the  internal  jugular  vein  is  indicated  in  otitis 
media,  and  in  furuncle  of  the  lips  (in  the  latter,  also, 
ligation  of  the  anterior  facial  vein). 

Phlegmasia  alba  dolens  does  not  suppurate  as  a 

187 


rule  and  can  be  treated  by  rest  in  bed  and  the  appli- 
cation of  mercurial  or  silver  ointments  (unguentum 
cinereum  and  unguentum  Crede). 

Fig.  84  shows  acute  purulent  thrombo-phlebitis  in 
a  woman,  affecting  a  varicosity  of  the  saphenous  vein, 
which  developed  after  pregnancy.  There  is  diffuse 
redness,  with  yellowish  nodules  indicating  the  com- 
mencement of  abscesses  in  connection  with  the 
infiltrated  and  thrombosed  vein. 


188 


Bockenheinicr,  Atlas. 


Tab.   I  Wll 


Ficr.  85.    Abscessus  subcutaneus. 


Rebman  Company,  New-York. 


ABSCESSUS  SUBCUTAKEUS  PARAMAMMILLARroS 

(Subcutaitcous  paramammillary  abscess) 
Plate  LXVn,  Fig.  83. 

The  term  abscess  is  applied  to  a  circumscribed 
collection  of  pus  which  arises  from  loss  of  tissue. 
The  terms  purulent  exudation  or  empyema  are 
applied  to  collections  of  pus  which  form  in  pre- 
existing cavities  (maxillary  antrum,  pleura,  abdo- 
men). Abscesses  may  occur  in  the  skin,  subcuta- 
neous tissue,  muscles,  bones,  and  also  in  the  internal 
organs  (liver,  lungs,  brain). 

Cold  abscesses,  which  are  due  to  chronic  infec- 
tions, such  as  tuberculosis  (Fig.  12.5),  must  be  dis- 
tinguished from  acute  abscesses,  which,  in  most 
cases,  occur  in  the  subcutaneous  tissue  as  the  result 
of  acute  pyogenic  inflammation,  due  to  staphy- 
lococci and  streptococci.  The  formation  of  an 
abscess  may  usually  be  considered  a  favorable  sign, 
as  it  arrests  the  progress  of  infection  in  the  organism 
by  damming  up  the  inflammation.  After  the  difi'use 
inflammation  has  become  circumscribed  in  the  form 
of  abscess,  the  severe  inflammatory  symptoms  sub- 
side. Granulation  tissue  formed  by  the  fixed  con- 
nective-tissue cells  forms  a  continuous  boundary 
known  as  the  abscess  membrane. 

The  majority  of  abscesses  arise  from  diffuse,  infil- 
trating, purulent  inflammation  of  the  subcutaneous 
tissue.  Abscesses  also  occur  in  the  various  organs 
of  the  body  in  all  other  pyogenic  affections  (erysipe- 
las, lymphangitis,  osteomyelitis,  lymphadenitis,  my- 
ositis). The  abscesses  may  spread  from  the  deeper 
parts  to  the  surface,  or  inversely. 

189 


Blood  efiFusions  may  suppurate  and  form  abscesses 
if  another  part  of  the  body  is  invaded  by  bacteria 
{e.g.  furuncle).  The  so-called  embolic  or  metastatic 
abscesses  are  formed  by  way  of  the  blood  stream  in 
general  infection,  and  may  occur  in  any  part  of  the 
body. 

The  clinical  symptoms  are  those  already  men- 
tioned. In  subcutaneous  abscess  the  skin  is  at  first 
red,  and  shows  diffuse  inflammatory  infiltration. 
There  is  pain,  tension  and  fever.  The  red  color  of 
the  skin  becomes  gradually  darker  and  more  circum- 
scribed. The  skin  becomes  thinner  and  yellowish 
and  bulging  at  one  spot,  through  which  the  abscess 
bursts.  The  deeper  the  abscess,  the  more  diffuse 
and  extensive  are  the  infiltration  and  inflammatory 
oedema  {e.g.  in  osteomyelitis.  Fig.  82). 

Erysipelas,  lymphangitis,  and  other  pyogenic  affec- 
tions may  be  present  along  with  abscess  formation. 
The  part  of  the  body  affected  is  stiff  and  painful  on 
movement,  and  as  every  abscess  may  lead  to  general 
infection  all  movements  should  be  avoided. 

Differential  Diagnosis.  Acute  abscess  is  recog- 
nized by  the  presence  of  all  the  symptoms  of  acute 
inflammation.  The  cause  of  the  abscess  must  be 
found,  and  the  occurrence  of  metastatic  abscesses 
must  be  borne  in  mind. 

Treatment.  As  soon  as  an  acute  abscess  is  diag- 
nosed by  the  presence  of  fluctuation,  or  by  an  explor- 
ing syringe  in  the  case  of  deep  abscess,  it  must  be 
freely  opened.  When  the  suppuration  is  once  cir- 
cumscribed, early  incision  prevents  further  destruc- 
tion of  tissue,  leads  to  quicker  healing  and  leaves  less 
scar.  Treatment  by  hot  fomentations  or  poultices, 
to  cause  spontaneous  bursting  of  the  abscess,  causes 
more  destruction  of  tissue  and  delays  healing. 

After  incision  the  abscess  should  be  plugged  with 
sterile  gauze,  after  which  granulation  tissue  is  quickly 

190 


formed.     Treatment  by  aspiration  is  not  so  good  as 
it  does  not  remove  the  abscess  membrane. 

Deep  abscesses  must  be  freely  opened,  plugged 
and  drained.  In  large  abscesses  a  counter  incision 
should  be  made  at  the  deepest  part  of  the  abscess 
cavity,  and  all  recesses  should  be  opened  up.  The 
affected  part  should  be  then  immobilized. 

Fig.  85  shows  a  subcutaneous  abscess  surrounding 
the  nipple  in  a  lying-in  woman,  arising  from  a  cracked 
nipple,  which  gave  entrance  to  bacteria.  The  skin 
round  the  nipple  is  bluish  red  and  swollen.  The  pres- 
ence of  fluctuation  indicates  a  collection  of  fluid  in 
the  subcutaneous  tissue.  The  inflammation  has 
already  become  circumscribed.  In  spite  of  the 
apparently  slight  extent  of  the  abscess,  the  patient 
suffered  from  severe  pain,  fever  and  general  malaise. 
The  abscess  healed  quickly,  after  incision  and  plug- 
ging and  suspension  of  both  breasts. 


191 


MASTITIS  PUERPERALIS  PURULENTA 

(Purulent  puerperal  mastiiis) 
Plate  LXVIII,  Fig.  86. 

Bacterial  inflammation  of  the  breast  (phlegmonous 
mastitis)  ending  in  suppuration  (purulent  mastitis), 
occurs  almost  exclusively  in  women  during  the  puer- 
perium,  as  the  result  of  direct  infection  of  the 
lactiferous  ducts  with  bacteria  (mostly  staphylo- 
cocci), through  cracks  and  fissures  of  the  nipple.  The 
clinical  symptoms  are  those  of  pyogenic  infection,  with 
the  formation  of  a  hard,  painful  infiltration,  usually 
in  the  lower  and  outer  quadrant  of  the  breast.  The 
skin  is  tense,  oedematous,  reddened  and  often  glisten- 
ing. The  redness  qviickly  extends  over  the  whole 
mamma  and  beyond  it.  The  patients  suffer  from  a 
feeling  of  tension  in  the  breast,  and  radiating  pain 
in  the  arm  of  the  affected  side.  There  is  also  general 
malaise.  The  affection  is  often  ushered  in  by  rigors 
and  high  temperature. 

The  axillary  glands  may  be  enlarged  and  painful. 
In  severe  cases  there  is  diftuse  infiltration  of  the 
whole  mammary  gland,  which  may  extend  into  the 
lymphatic  vessels  round  the  breast.  Abscesses  form 
in  one  or  more  places;  the  superficial  ones  being 
recognized  by  fluctuation,  the  deeper  ones  by  the 
extensive  nature  of  the  lesion.  Purulent  inflamma- 
tion of  the  mamma  may  occur  in  general  infection; 
on  the  other  hand,  it  may  also  give  rise  to  general 
infection  by  thrombo-phlebitis. 

Differential  Diagnosis.  A  non-bacterial  in- 
flammation of  the  breast  occurs  in  sucklings  soon 
after  birth  (mastitis  neonatorum).     This  is  a  physio- 

192 


Bockenlieimer,  Atlas. 


Tab.  I. .Will. 


Fig.  80.    MasUlis  puer|ieralis  iiurulciita. 


Rcbman  Coiiinnnv.  Nc'»-\'ork. 


logical  swelling  of  the  gland  with  excretion  of  a 
secretion  resembling  milk.  In  some  cases  there  is 
circumscribed  abscess  formation,  which  soon  heals 
after  incision.  The  inflammation,  however,  usually 
subsides  under  ointments  and  moist  fomentations. 
Similar  mastitis  may  occur  at  the  age  of  puberty, 
both  in  boys  and  girls,  which  yields  to  the  same 
treatment  and  seldom  leads  to  abscess.  Pigmenta- 
tion of  the  areola  remains  after  these  cases  of 
mastitis. 

During  the  period  of  lactation,  accumulation  of 
milk  due  to  stopping  its  outflow  may  cause  hard  in- 
flammatory infiltration  of  the  breast  (milk  abscess) 
which  disappears  after  removal  of  the  milk  by  a 
breast  pump,  etc.  In  these  cases  both  breasts 
should  be  supported  by  a  suspensory  bandage. 

Mastitis  may  be  caused  by  trauma,  by  suppuration 
in  a  blood  eft'usion  caused  by  injury.  In  cases  of 
furunculosis  and  diabetes  mastitis  may  occur,  with 
the  formation  of  hard,  deeply  situated  abscesses 
resembling  malignant  tumors. 

Tuberculous  mastitis  is  generally  due  to  extension 
from  tuberculous  axillary  glands  and  is  characterized 
by  its  chronic  course.  Actinomycosis  gives  rise  to 
hard  swellings  (cf.  Fig.  115).  Syphilis  may  also 
cause  interstitial  mastitis,  but  there  is  no  suppura- 
tion. Gonorrheal  infection  of  the  lactiferous  ducts 
has  also  been  described,  as  the  result  of  uncleanliness 
of  the  mother,  or  gonorrheal  stomatitis  in  the  infant. 

Interstitial  mastitis  and  chronic  cystic  mastitis 
which  form  tumor-like  nodules  in  the  mamma,  can- 
not be  mistaken  for  phlegmonous  mastitis  as  they 
cause  no  acute  inflammatory  symptoms. 

Superficial  abscesses  in  the  region  of  the  nipple 
(Fig.  85)  are  easily  distinguished  from  purulent  mas- 
titis, and  are  only  of  limited  extent.  Retro-mam- 
mary abscesses  may  cause  difficulty  in  the  diagnosis 
when  there  are  also  signs  of  inflammation  in  the 
mamma.     In  these  eases  the  skin  is  usually  intact, 

193 


the  whole  breast  is  raised  from  the  thorax,  and  pal- 
pation of  the  breast  causes  no  pain ;  but  there  is  pain 
on  pressing  the  breast  against  the  thorax.  There  is 
generally  acute  adenitis  of  the  axillary  glands  and 
pain  on  moving  the  arm  in  retro-mammary  abscess. 

Treatment.  As  soon  as  suppuration  in  the  breast 
is  diagnosed  it  must  be  incised.  The  earlier  incision 
is  made  the  more  rapidly  do  the  symptoms  subside. 
The  case  should  not  be  left  till  the  abscess  points 
under  the  skin,  but  a  radial  incision  should  be  made, 
under  an  anaesthetic,  through  the  breast  tissue,  if  nec- 
essary as  far  as  the  pectoral  fascia.  All  recesses  and 
pockets  must  be  opened  up,  and  counter-openings 
made  if  necessary.  Glandular  tissue  destroyed  by 
suppuration  can  be  removed  with  the  sharp  spoon. 

The  after-treatment  consists  in  plugging  and  drain- 
age, and  must  be  carefully  carried  out,  otherwise 
there  may  be  purulent  infiltration  of  the  neighboring 
gland  lobules  and  further  extension  in  the  form  of 
diffuse  inflammation.  Large  incisions  are  indicated, 
as  they  lead  to  more  rapid  healing,  and  enable  the 
mammary  gland  to  retain  its  function  of  lactation. 
Both  breasts  should  be  suspended,  and  the  child 
removed  from  the  breast.  Purgatives  and  iodide  of 
potassium  may  be  given  to  diminish  the  formation 
of  milk.  Treatment  by  moist  fomentations  is  not 
to  be  recommended,  as  it  may  lead  to  destruction  of 
the  whole  glandular  tissue. 

Treatment  of  the  abscess  by  aspiration,  which 
aims  at  the  least  possible  destruction  of  the  mam- 
mary tissue,  is  only  indicated  in  the  rare  cases  where 
the  inflammation  and  abscess  formation  is  circum- 
scribed. In  the  more  common  phlegmonous  form 
this  method  is  dangerous,  and  has  in  more  than  one 
instance  necessitated  amputation  of  the  breast.  Aspi- 
ration has  also  the  disadvantage  of  being  uncleanly. 

Fig.  86  shows  a  case  of  acute  purulent  mastitis  in 
a  lying-in  woman,  situated  in  the  lower  and  outer 

194 


quadrants  of  the  breast.  It  may  be  mentioned,  by 
the  way,  that  congestive  mastitis  of  the  lower  quad- 
rants of  the  breast  may  predispose  to  infective  mas- 
titis. In  Fig.  86  the  inflammatory  signs  are  very 
marked.  The  skin  is  reddened,  tense  and  infiltrated ; 
the  whole  of  the  outer  and  lower  part  of  the  mamma 
is  hard  and  painful.  Fluctuation  was  nowhere 
present.  The  case  healed  rapidly  after  incision, 
plugging  and  suspension. 

Persistent  fistulas  of  the  breast  with  unhealthy 
granulations  (cf.  Fig.  56)  may  be  due  to  deep  col- 
lections of  pus  which  have  not  been  opened  up,  or 
to  tampons  or  drainage  tubes  which  have  been  left 
behind.     They  often  require  multiple  incisions. 


195 


FURUNCULUS— LYMPHANGITIS  {Furuncle— Li/mphangUis) 

Plate  LXIX,  Fig.  87. 
FURHNCULOSIS   (Fnruneulosis) 

Plate  LXIX,  Fig.  88. 

Bacterial  invasion  of  the  skin  occurs  through  the 
ducts  of  the  sebaceous  glands.  Even  slight  friction 
is  sufficient  to  cause  staphylococci,  which  are  always 
present  on  the  skin,  to  enter  the  sebaceous  glands, 
where  they  find  more  favorable  conditions  for  their 
growth  than  on  the  surface  of  the  skin.  In  uncleanly 
persons  pustules  often  occur  on  the  skin,  each  one 
pierced  by  a  hair.  This  purulent  inflammation  of 
the  sebaceous  glands  is  called  folliculitis.  In  the 
eyelids  folliculitis  of  the  eyelashes  forms  hordeolum, 
or  stye.  Folliculitis  is  cured  by  epilation  of  the 
hairs,  and  may  be  avoided  by  cleanliness. 

The  inflammation  may  extend  beyond  the  seba- 
ceous gland  and  cause  inflammatory  infiltration  of 
the  skin.  Furuncle  (boil)  is  a  circumscribed  pyogenic 
affection  of  the  skin  caused  generally  by  staphylo- 
cocci, sometimes  by  streptococci  and  other  bacteria. 
The  pathological  process  consists  in  hyperaemia  and 
exudation,  with  redness  and  hard  swelling  of  the 
skin,  followed  by  necrosis  of  the  tissue  in  the  center 
of  the  infiltration;  afterwards  regeneration  by  the 
formation  of  granulation  tissue.  Furuncles  occur 
especially  in  parts  which  are  exposed  to  irritation — 
the  nape  of  the  neck,  the  wrist  joint,  the  buttocks, 
the  thigh  and  the  face.  Furuncles  often  occur  sec- 
ondary to  cracked  conditions  of  the  skin  caused  by 
eczema,  excoriations,  etc.  In  diabetics,  furuncles  are 
very  common  owing  to  the  dry  condition  of  the  skin 
and  the  scratching  produced  by  pruritus,  also  to  the 

196 


Bockenheimer,  Atlas. 


Tab.  I.XIX 


CO 


i;: 


P^hman    Pr. 


Ma...    V'n..U 


body  being  especially  vulnerable  to  bacterial  inva- 
sion (Fig.  140).  Furuncles  may  also  appear  in  all 
cases  where  the  bodily  resistance  is  impaired — in  chil- 
dren, old  people,  and  the  tuberculous. 

The  clinical  appearance  of  furuncle  is  typical. 
From  a  small  punctiform  redness  develops  a  hard, 
redder,  painful  nodule  in  the  skin,  which  extends  at 
its  periphery  and  also  deeply  towards  the  fascia. 
The  epidermis  is  at  first  intact,  but  afterwards  rup- 
tures at  the  apex  of  the  projecting  furuncle,  exposing 
a  yellowish  center  which  becomes  more  and  more 
demarcated  from  the  hard,  red  infiltration.  In  this 
way  a  round,  crateriform  ulcer  is  produced  with  a 
central  yellowish  core  (Fig.  87).  Sometimes  a  hair 
is  situated  in  the  center  of  the  furuncle.  Large  fur- 
uncles are  extremely  painful,  especially  on  move- 
ment, and  are  often  accompanied  by  fever  and 
general  debility.  The  symptoms  subside  when  the 
central  core  becomes  loosened  by  suppuration.  The 
cavity  is  then  cjuickly  filled  by  granulation  tissue, 
which  may  form  a  cicatrix  in  a  few  days.  The  hard 
infiltration  remains  for  a  long  time  and  generally 
causes  unpleasant  itching  of  the  skin.  The  scar, 
which  is  always  hypertrophic  in  all  inflammatory 
processes,  may  also  cause  trouble. 

Complications  may  increase  the  severity  of  fur- 
uncle. There  is  always  lymphangitis,  especially  in 
the  extremities,  and  often  lymphadenitis.  Early  im- 
plication of  the  lymphatics  signifies  extensive  inflam- 
mation and  virulent  bacteria. 

Several  furuncles  are  sometimes  found  close  to- 
gether, either  from  simultaneous  infection  of  several 
sebaceous  glands  or  from  secondary  infection  from 
the  primary  furuncle.  This  often  occurs  after  the 
application  of  plaster  or  other  measures  with  the 
object  of  "drawing  out"  the  furuncle. 

In  individuals  with  a  feeble  power  of  resistance 
(diabetics,  infants  and  old  people),  there  maybe  an 
outbreak  of  furuncles  over  the  whole  body,  a  condi- 

197 


tion  known  as  jurunculosis  (Fig.  88).  In  children 
this  process  often  consists  in  the  formation  of  multiple, 
small  nodular  infiltrations  in  the  skin,  in  which  there 
is  no  central  core  but  a  small  abscess.  Extensive 
furunculosis  may  be  fatal  from  exhaustion.  As  in 
every  pyogenic  infection,  furunculosis  may  lead  to 
purulent  thrombo-phlebitis  and  general  pyogenic  in- 
fection. Furuncle  of  the  lip  may  cause  meningitis  by 
thrombo-phlebitis  of  the  facial  vein,  and  general 
infection  may  be  caused  by  thrombo-phlebitis  of  the 
veins  of  the  neck  (Fig.  108).  Furuncles  may  lead  to 
renal  abscess  and  osteomyelitis  (Fig.  104),  especially 
when  not  properly  treated. 

Differential  Diagnosis.  Furuncles  arising  from 
sebaceous  glands  are  so  characteristic  that  they  can- 
not be  mistaken.  Metastatic  furuncles  in  general 
infection  are  multiple,  and  are  associated  with  other 
pyogenic  affections. 

Furuncles  arising  from  the  sweat  glands  develop 
under  the  skin  and  form  subcutaneous  abscesses. 
These  occur  in  hairy  regions  where  there  is  much 
excretion  of  sweat,  such  as  the  axilla.  They  must 
not  be  confounded  with  the  more  deeply  situated 
glandular  abscesses.  They  generally  affect  several 
sweat  glands  and  form  multiple  superficial  abscesses, 
in  distinction  to  lymphadenitis,  which  either  assumes 
a  diffuse  phlegmonous  form,  or  is  converted  into  a 
large  abscess. 

Treatment.  Individuals  who  have  a  tendency  to 
furunculosis  should  take  precautions  against  infec- 
tion, by  careful  attention  to  hygiene;  frequent  baths, 
rubbing  ointment  into  dry,  cracked  skin,  etc. 

Small  furuncles  can  sometimes  be  aborted  by  fre- 
quent friction  with  sulphuric  ether,  or  spraying  with 
ethyl  chloride.  When  painful  infiltration  of  the  skin 
has  developed,  the  best  method  is  an  incision  extend- 
ing through  the  whole  depth  and  breadth  of  the  infil- 

198 


tratiou,  after  careful  disinfection  of  tlie  skin,  under 
local  anaesthesia.  There  is  no  need  to  wait  for  com- 
plete separation  of  the  core,  but  the  incision  may  be 
made  as  soon  as  necrosis  is  commencing,  which  is 
shown  by  rupture  of  the  skin  in  the  center.  Early 
incision  diminishes  pain  and  lymphangitis  and  has  a 
favorable  influence  on  the  whole  process.  Larger 
furuncles  require  a  crucial  incision.  After  incision 
the  wound  should  be  loosely  plugged  with  iodoform 
gauze.  The  core  generally  separates  within  twenty- 
four  hours.  The  core  must  never  be  forcibly  ex- 
pressed, as  this  causes  irritation  of  the  inflamed 
tissues,  suppuration  in  the  lymphatics,  and  delay  in 
healing.  Friction  of  the  skin  with  ether  is  useful  at 
each  change  of  the  dressings.  As  soon  as  granula- 
tions appear  the  plugging  should  be  left  off,  and  the 
formation  of  granulations  promoted  by  ointments 
and  the  nitrate  of  silver  crayon.  In  the  extremities 
absolute  immobilization  with  suspension  is  necessary 
till  complete  healing  has  taken  place,  otherwise  heal- 
ing is  delayed  or  fresh  infection  follows.  The  cica- 
trices may  be  treated  with  iodide  of  potassium  oint- 
ment. 

Incision  by  the  thermo  cautery  is  not  to  be  recom- 
mended, as  the  formation  of  eschars  hinders  the 
exit  of  infectious  secretion.  Moist  fomentations  are 
also  to  be  avoided,  as  they  cause  greater  destruction 
of  tissue  and  often  lead  to  extensive  furunculosis. 
Dry  cupping  has  been  recommended  both  as  an 
abortive  method,  and  also  for  removal  of  the  core. 

Furunculosis  of  young  children  should  be  treated 
by  incision  of  the  multiple  abscesses,  followed  by 
antiseptic  baths.  The  skin  must  be  kept  clean  to 
avoid  recurrence.  In  adults  the  general  health 
requires  treatment,  by  purgatives,  etc.  Yeast  prepa- 
rations have  also  been  recommended.  Diabetic  fur- 
uncle requires  special  treatment. 


199 


LYMPHANGITIS 

In  pyogenic  affections  the  lymphatic  vessels  and 
glands  exercise  a  beneficial  function  by  harboring 
and  destroying  bacteria  and  their  products.  If  the 
bacterial  invasion  is  very  severe,  or  the  bacteria  very 
virulent,  the  lymph  is  coagulated  and  inflammation 
takes  place  in  the  walls  of  the  lymphatics,  first  as 
hypersemia,  later  as  small-celled  infiltration  of  the 
walls  of  the  vessels.  Virulent  bacteria  may  give  rise 
to  lymphangitis  and  lymphadenitis  (Fig.  110)  through 
slight  abrasions  of  the  skin,  or  in  connection  with 
pyogenic  affections,  such  as  whitlow,  furunculosis,  etc. 

Lymphangitis  is  most  clearly  observed  in  the  super- 
ficial lymphatics  of  the  extremities,  in  the  form  of 
red,  diffuse  patches,  which  soon  develop  into  irregular 
red  cords  extending  from  the  periphery  to  the  root  of 
the  limb.  The  number  of  cords  diminishes  in  the 
upper  part  of  the  limb,  and  eventually  only  one  large 
cord  remains  in  the  region  of  the  lymphatic  glands 
(inguinal  or  axillary).  These  signs  are  most  marked 
in  infection  by  virulent  bacteria. 

The  lymphatic  cords  are  somewhat  raised  above 
the  level  of  the  skin  and  feel  hard.  They  are  painful 
to  touch  and  on  movement.  There  is  also  itching 
and  a  feeling  of  tension  in  the  whole  limb.  The 
regional  lymphatic  glands  are  at  the  same  time 
swollen  and  painful.  In  some  places  abscesses  form 
in  the  hard  cords.  There  is  generally  fever  and 
rigors. 

Lymphangitis  of  the  deep  IjTiiphatics  of  the  extrem- 
ities can  be  recognized  by  the  feeling  of  tension  and 
the  general  symptoms.     Peritonitis  may  give  rise  to 

200 


picuritis  through  the  lymphatic  vessels  of  the  dia- 
phragm. 

The  prognosis  of  lymphangitis  is  generally  favor- 
able, as  it  disappears  after  removal  of  the  cause. 

Chronic  lymphangitis,  caused  by  long-continued 
irritation  of  the  skin,  eczema,  ulcers,  etc.,  gives  rise  to 
hard,  cord-like  formations,  which  persist  for  a  long 
time.  Obliteration  of  the  lymphatics  may  cause 
elephantiasis. 

Differential  Diagnosis.  Similar  symptoms  are 
caused  by  acute  purulent  thrombo-phlebitis  (Fig. 
84),  but  the  cords  are  thicker  and  not  so  numerous. 

Treatment.  This  consists  in  treatment  of  the 
primary  affection  which  causes  the  lymphangitis 
(furuncle,  etc.)  and  in  absolute  immobilization  of  the 
limb,  with  suspension.  The  thickened  lymphatic 
cords  may  be  painted  with  mercury  or  silver  oint- 
ments (unguentum  cinereum,  unguentum  Crede), 
but  these  should  not  be  forcibly  rubbed  in.  In 
chronic  lymphangitis,  baths  and  massage  are  indi- 
cated.    Abscesses  must  be  incised. 

Fig.  87  shows  a  furuncle  with  lymphangitis.  It 
was  cured  in  eight  days  by  incision,  iodoform  gauze, 
plugging  and  suspension  of  the  arm. 

Fig.  88  shows  a  case  of  furunculosis  in  a  young 
child.  Abscess  formation  is  seen  in  the  center  of 
the  furuncles.  The  case  was  cured  by  incisions  and 
almond  bran  baths. 


201 


CARBITNCULUS   (Carbuncle) 
Plate  LXX,  Fig.  89. 

Carbuncle,  which  generally  occurs  in  middle  life, 
differs  from  furuncle  only  its  greater  extent,  both 
superficially  and  deeply.  It  consists  of  an  infection 
of  several  sebaceous  glands,  thus  forming  an  agglom- 
eration of  furuncles.  The  skin  gives  way  in  several 
places  and  there  are  several  yellow  cores.  Com- 
mencing as  a  small,  red  nodule,  it  quickly  develops 
into  a  hard  infiltration,  extending  to  the  fascia,  and 
may  eventually  attain  the  size  of  a  hand,  and  cause 
more  or  less  diffuse  inflammatory  infiltration  of  the 
neighboring  parts.  Lymphangitis  and  lymphade- 
nitis are  generally  present.  The  affection  is  accom- 
panied by  severe  pain,  high  fever  and  rigors. 

Carbuncle  is  generally  caused  by  streptococcal 
infection.  Eczema  and  other  affections  of  the  skin 
which  cause  furuncle,  may  also  give  rise  to  carbuncle. 
Moreover,  furuncle  may  develop  into  carbuncle, 
especially  when  the  core  has  been  forcibly  expressed, 
or  when  hot  fomentations  have  been  applied.  In 
diabetics  carbuncle  is  still  more  common  than  fur- 
uncle, and  leads  to  extensive  necrosis  of  the  fascia; 
it  often  causes  death  from  exhaustion.  Carbuncle  of 
the  face  is  dangerous  owing  to  its  liability  to  cause 
general  infection,  or  meningitis  by  infection  of  the 
facial  vein.  Carbuncle  of  the  nape  of  the  neck  may 
attain  enormous  size,  and  extend  from  one  ear  to  the 
other. 

Differential  Diagnosis.  Anthrax  (malignant 
pustule)  differs  from  carbuncle  in  the  presence  of 
small  vesicles  .filled  with  turbid  fluid  and  early  cen- 

202 


Bockenheimer,  Atlas. 


Tab.  LXX. 


Fig.  8Q.    Carbunculus. 


Rcbman  Company,  New-York. 


tral  necrosis  of  the  skin,  and  in  the  absence  of  cores. 
In  doubtful  cases  a  bacteriological  examination  must 
be  made. 

Treatment.  Under  an  antesthetic,  a  crucial  inci- 
sion is  made  through  the  whole  extent  and  depth  of 
the  carbuncle,  and  the  central  necrosed  parts  excised. 
The  wound  is  plugged  with  iodoform  gauze. 

In  diabetic  carbuncle,  progressive  neci'osis  of  the 
fascia  often  necessitates  counter-incisions.  Iodoform 
gauze  should  not  be  used  in  these  cases,  but  sterile 
gauze.     Special  treatment  is  required  for  the  diabetes. 

In  every  carbuncle  there  is  severe  constitutional 
disturbance  which  requires  general  treatment  by 
nourishing  diet,  etc. 

Fig.  90  shows  a  carbuncle  of  the  nape  of  the  neck 
in  a  patient  of  forty.  The  infiltration  is  very  exten- 
sive. In  the  central  parts  the  skin  is  ruptured  in 
several  places,  and  shows  the  deeply  situated,  ne- 
crotic cores.  Round  this  is  a  zone  of  reddish-blue 
skin,  and  beyond  this  zone  an  area  of  hard,  red  infil- 
tration. There  was  high  fever.  The  case  healed 
under  the  above-mentioned  treatment. 


203 


ERYSIPELAS    ERYTHEMATOSUM  (Erysipelas) 
Plate  LXXI,  Fig.  90. 

While  in  lymphangitis  the  deeper  and  larger 
lymphatics  are  infected,  in  erysipelas  the  smaller 
lymphatic  spaces  of  the  skin  and  subcutaneous  tissue 
are  plugged  with  streptococci.  A  similar  condition 
may  occur  in  the  superficial  layers  of  the  mucous 
membranes.  The  causes  of  this  bacterial  infection 
are  streptococci  (Fehleisen),  but  their  identity  with 
the  streptococcus  pyogenes  is  not  yet  agreed  upon. 

The  affected  skin  is  red,  tense,  somewhat  glistening 
and  slightly  raised  above  the  level  of  the  rest  of  the 
skin.  The  borders  are  well-defined,  distinctly  raised 
and  zigzag,  so  that  the  extension  of  erysipelas,  espe- 
cially on  the  face,  has  been  compared  to  lambent 
flames.  When  the  disease  spreads  over  the  whole 
body,  it  is  spoken  of  as  migratory  erysipelas. 

Erysipelas  may  occur  wherever  there  is  a  solution 
of  continuity  in  the  skin — after  scratches  and  excoria- 
tions, after  all  injuries  and  operation  wounds.  It 
may  also  be  combined  with  various  pyogenic  affec- 
tions— whitlow  and  phlegmon  (especially  staphylo- 
coccal phlegmon).  Conditions  which  give  rise  to  con- 
stant irritation  of  the  skin,  such  as  lupus,  tuberculous 
fistula,  ulcer  of  the  leg,  foreign  bodies,  etc.,  may  also 
give  rise  to  erysipelas,  which  is  then  often  relapsing. 
Relapsing  erysipelas  of  the  face  and  leg  may  cause 
elephantiasis.  Lastly,  erysipelas  may  arise  in  gen- 
eral streptococcal  infection,  and  is  then  always  com- 
bined with  other  pyogenic  conditions — abscess,  phleg- 
mon, etc. 

The  common  form  of  erysipelas,  which  consists  in 
a  red  elevation  of  the  skin,  is  called  erythematous 

204 


Bockenheimer,  Atlas. 


Tab.  1  .\.\l 


Fiy.  QO.    Hrvsipelas  crvlliematosiiin. 


Dffhmin     Cnw^^.^^,.       NTai.-    Va.-!/ 


erysipelas  (Fig.  90).  In  bulbous  erysipelas  the  skin 
is  covered  with  vesicles  (Fig.  91).  In  hemorrhagic 
erysipelas  there  is  hemorrhage  in  the  skin  (Fig.  91). 
In  the  great  majority  of  cases  there  is  resolution,  but 
sometimes  erysipelas  may  cause  cutaneous  abscesses, 
and  in  the  form  of  gangrenous,  phlegmonous  erysipe- 
las may  give  rise  to  ulceration  and  extensive  destruc- 
tion of  the  skin. 

The  clinical  sjTnptoms  of  erysipelas  are  character- 
istic. The  disease  usually  commences  by  a  rigor, 
high  temperature  (40°-42°  C.)  and  redness  of  the 
skin.  There  is  itching  and  tension  in  the  skin,  and 
tenderness  on  pressure.  There  is  considerable  con- 
stitutional disturbance  owing  to  high  fever,  head- 
ache and  vomiting  which  continue  while  the  disease 
progresses.  The  temperature  falls  suddenly,  the 
redness  ceases  to  extend,  and  the  skin,  after  slio;ht 
desquamation  resumes  its  normal  condition  in  about 
a  week  from  the  onset  of  the  disease.  In  relapsing 
erysipelas  the  whole  process  may  take  place  within 
one  or  two  days.  Erysipelas  occurs  most  frequently 
on  the  face,  after  this  on  the  exti'emities  and  genital 
organs.  In  places  where  the  skin  is  loosely  attached 
(eyelids,  scrotum),  there  may  be  considerable  swell- 
ing and  oedema. 

Erysipelas  of  the  mucous  membranes  is  generally 
difficult  to  recognize,  except  when  it  is  an  extension 
from  erysipelas  of  the  skin.  The  mucous  membrane 
is  swollen,  oedematous,  sodden  and  of  a  deep-red 
color.  Constitutional  disturbance  is  o;enerallv  severe. 
Erysipelas  of  the  buccal  mucous  membrane  may 
occur  after  tooth  extraction  with  dirty  instruments. 
It  may  cause  death  by  meningitis  or  oedema  of  the 
glottis.  The  average  mortality  of  erysipelas  is  ten 
per  cent. 

Differential  Diagnosis.  Erythematous  erysipe- 
las is  so  characteristic  that  it  can  hardly  be  mistaken 
for  other  affections.     The  advancing,  irregular,  raised 

205 


edge  distinguishes  it  from  other  inflammatory  condi- 
tions. 

Treatment.  The  affected  parts  must  be  covered 
with  antiseptic  ointments  to  prevent  infection  and 
auto-infection.  If  pain  is  very  severe  scarifications 
are  useful.  In  erysipelas  of  the  extremities  the 
healthy  skin,  at  the  upper  limit  of  the  lesion,  may  be 
painted  with  a  single  application  of  pure  carbolic 
acid,  which  destroys  the  superficial  layers  of  the  skin. 
However,  in  spite  of  this  procedure,  the  erysipelas 
often  extends  further  up  the  limb.  The  induction 
of  passive  hypersemia,  by  surrounding  the  limb  with 
adhesive  plaster,  has  also  been  recommended.  Among 
other  methods,  painting  with  iodine  may  be  men- 
tioned.    The  patient  should  always  be  kept  in  bed. 

Serum  therapy  has  so  far  proved  useless,  and  is 
likely  to  remain  so,  since  repeated  attacks  of  the 
disease  do  not  confer  immunity. 

The  formerly  extolled  curative  action  of  erysipelas 
on  tumors  has  proved  illusory.  If  erysipelas  extends 
over  a  malignant  tumor  (carcinoma  or  sarcoma),  the 
tumor  may  diminish  in  size  owing  to  destruction  of 
its  cells,  but  it  soon  begins  to  grow  again.  The  same 
thing  occurs  after  injection  of  the  fluid,  and  this 
explains  the  temporary  action  of  the  so-called  cancer 
serum. 

On  account  of  the  infectious  nature  of  the  disease, 
the  patient  should  be  isolated,  and  the  room  disin- 
fected with  formalin  vapor.  The  same  disinfection 
must  be  carried  out  in  operation  theaters  when  an 
epidemic  of  erysipelas  occurs.  However,  it  is  more 
often  the  hands  of  the  surgeon  which  convey  infec- 
tion; hence  great  care  must  be  taken  in  avoiding 
contact  with  the  patient  as  much  as  possible,  and 
in  disinfecting  the  hands. 

Fig.  90  shows  a  typical  case  of  erythematous  ery- 
sipelas of  the  face,  which  originated  from  a  fissure  on 

206 


the  nose.  In  a  few  days  there  occurred  high  fever 
and  rigors,  followed  by  erysipelas,  first  on  one  side 
of  the  face,  then  on  the  other.  The  skin  was  tense, 
purple  and  somewhat  raised.  There  was  considera- 
ble pain  and  itching.  The  eyelids  were  so  oedema- 
tous  that  the  patient  could  hardly  open  them.  The 
lips  were  also  much  swollen,  and  there  was  com- 
mencing erysipelas  of  the  buccal  cavity.  The  sharp 
zigzag  borders  are  seen  towards  the  scalp  and  the 
neck. 


207 


ERYSIPELAS  BULLOSUM  H^MORRHAGICUM 

(Hemorrhagic  Bullous  Erysipelas) 
Plate  LXXII,  Fig.  91. 

This  case  is  interesting  on  account  of  the  origin  of 
the  infection  from  a  horse  bite  in  the  arm.  Round 
the  three  wounds  (which  were  only  superficial  abra- 
sions) the  skin  is  dark  red  and  there  are  annular 
extravasations  of  blood.  There  are  also  several 
vesicles  filled  with  turbid  fluid.  There  is  extensive 
diffuse  reddening,  especially  on  the  forearm,  and  a 
brownish  coloration  due  to  numerous  extravasations 
of  blood  from  the  smaller  blood-vessels  situated 
round  the  lymphatic  vessels.  In  the  upper  arm 
there  is  macular  and  cord-like  reddening  due  to 
lymphangitis.  The  axillary  glands  are  much  swollen 
and  painful. 

Wounds  caused  by  bites  from  animals  or  men  tend 
to  become  severely  infected.  In  this  case,  the  swell- 
ing of  the  forearm  was  so  extensive  that  a  deep 
phlegmon  was  suspected.  The  symptoms  quickly 
subsided  after  suspension  of  the  arm.  In  the  place 
where  the  erysipelas  was  hemorrhagic  and  bullous, 
there  occurred  a  superficial  phlegmonous  inflamma- 
tion, which  led  to  gangrene  of  the  skin. 

Differential  Diagnosis.  This  has  to  be  made 
from  several  other  affections.  Anthrax  also  com- 
mences with  redness  of  the  skin  and  the  formation  of 
vesicles  (Fig.  112),  fever  and  rigors,  and  may,  in  its 
early  stage,  be  confounded  with  this  form  of  erysipe- 
las. But  the  redness  is  not  so  extensive  in  anthrax, 
nor  so  rapidly  developed.  Anthrax  always  causes 
early    gangrene    of    the    skin.     In    doubtful    cases 

308 


Bockenheimer,  Atlas. 


Tab.  LXXII. 


hig.  91.     Erysipelas  biillosum  iiaiiioiThagiciim. 


anthrax  bacilli  must  be  looked  for  in  the  contents  of 
the  vesicles. 

In  this  case,  which  arose  from  a  horse  bite,  there 
was  a  suspicion  of  glanders.  But,  in  the  latter  the 
redness  is  punctiform  or  macular;  the  vesicles  are 
larger  and  purulent,  and  soon  rupture,  giving  rise  to 
gangrenous  ulcers. 

Subcutaneous  phlegmons,  which  arise  from  very 
virulent  streptococci,  may  cause  an  erysipelatous 
redness  of  the  skin,  but  this  only  occurs  in  the  region 
of  the  phlegmon,  and  does  not  extend  so  rapidly  as 
erysipelas.  Vesicles  may  also  form  on  the  skin  in 
virulent  streptococcal  infection. 

Phlegmons  due  to  gas-forming  bacteria  (e.g.  malig- 
nant oedema.  Fig.  109)  cause  rapid  redness  and  swell- 
ing of  a  whole  limb.  Increase  of  pressure  in  the 
tissues  from  the  formation  of  gas  also  gives  rise  to 
the  formation  of  vesicles,  but  these  are  very  large 
and  often  raise  the  epidermis  over  the  whole  part 
afi'ected  (Fig.  109).  In  these  severe  forms  of  phleg- 
mon there  are  signs  of  general  infection  from  the  be- 
ginning— rigors,  delirium,  diarrhea,  dry  tongue,  and 
bacteria  in  the  blood. 

In  all  the  above-mentioned  cases  the  clinical  pic- 
tures may  be  very  similar,  and  the  diagnosis  should 
always  be  established  by  bacteriological  examination. 
Correct  diagnosis  is  all  the  more  important  to  estab- 
lish, as  the  treatment  differs  in  the  different  afi'ections. 
In  erysipelas,  anthrax  and  glanders  conservative 
treatment  is  indicated,  while  streptococcal  phlegmon 
requires  early  incision  to  prevent  general  infection 
and  in  gas-phlegmon  very  extensive  incisions,  or  even 
early  amputation  of  the  limb,  may  be  necessary  to 
save  the  patient's  life. 

In  Fig.  91  streptococci  were  found  in  the  vesicles, 
and  from  this,  together  with  the  clinical  symptoms 
the  diagnosis  was  made  of  hemorrhagic  bullous 
erysipelas;    but  the  possibility  of  a  deep  phlegmon 

209 


due  to  the  bite  still  remained.  However,  the  mild- 
ness of  the  constitutional  disturbance,  and  the  rapid 
disappearance  of  the  swelling  showed  it  to  be  a  case 
of  erysipelas  only.  Recovery  took  place  in  the  course 
of  three  weeks,  with  cicatrization  of  the  gangrenous 
part. 


210 


Bockenheimer,  Atlas. 


Tab.  LXXIII. 


Vlli.  92.    Iirysipcloid. 


Rfbnian  CoiiiDaiiy,  New-York. 


ERYSIPELOID 
Plate  LXXIII,  Fig.  92. 

An  affection  very  similar  to  erysipelas,  called 
chronic  erysipelas  by  Rosenbarh,  is  now  known  by 
the  term  erysipeloid.  This  is  also  a  bacterial  infec- 
tion of  the  skin  (according  to  Tavel,  also  of  tendon- 
sheaths  and  joint  capsules)  but  of  a  very  harmless 
nature.  The  specific  cause  of  erysipeloid  is  unknown ; 
in  some  cases  the  staphylococcus  albus  has  been 
found. 

The  affection  begins  with  redness  and  swelling  of 
the  fingers.  Like  erysipelas,  the  redness  has  sharp, 
irregular  borders.  The  redness  spreads  slowly  but 
continuously  over  the  whole  finger,  and  may  extend 
to  the  next  finger  and  as  far  as  the  wrist.  At  this 
point  the  inflammation  stops.  There  are  no  consti- 
tutional symptoms;  no  fever  nor  rigors.  The  pa- 
tients only  complain  of  itching  and  a  feeling  of  ten- 
sion in  the  skin.  In  some  cases  there  is  lymphangitis, 
generally  on  the  extensor  surface,  as  far  as  the  axilla. 
In  rare  cases  lymphadenitis  with  high  temperature 
has  been  observed. 

Erysipeloid  generally  occurs  after  injuries  to  the 
fingers,  especially  by  fish  and  game.  It  is,  therefore, 
more  common  in  venders  of  fish  and  game,  cooks, 
butchers,  curriers,  etc.  Sometimes  the  injured  spot 
is  invisible,  as  the  redness  and  swelling  generally 
appear  a  few  days  after  the  injury.  In  other  cases 
foreign  bodies  are  found  in  the  skin.  The  affection 
has  been  observed  in  doctors  after  operating  upon 
infected  persons.  The  symptoms  generally  subside 
in  a  week,  but  relapses  are  common.  The  disease  is 
more  common  in  the  autumn. 

211 


Differential  Diagnosis.  Erysipeloid  diflfers  from 
erysipelas  in  its  chronic  course,  absence  of  fever,  paler 
color,  and  demarcation  at  the  wrist. 

Treatment.  Ointments,  rest  and  support  on 
splints.  Movements  must  be  restricted  after  removal 
of  splints,  to  avoid  relapses.  Foreign  bodies  must  be 
removed.  Suppuration  has  never  been  observed. 
Baths  and  iodide  ointment  may  be  used  if  swelling 
persists. 

Fig.  92  shows  erysipeloid  in  a  cook,  which  appeared 
soon  after  handling  game.  A  few  days  after  a  slight 
wound,  redness  and  swelling  developed  at  the  tip  of 
the  right  forefinger,  and  gradually  extended  over  the 
whole  finger.  At  the  base  of  the  finger  the  edge  of 
the  redness  is  irregular  and  zigzag. 


212 


Panaritium  or  Panaris 

(WhUlou^ 

PANARITIUM  SUBEPIDERMOIDALE  {Sub-epidermic  whitlow) 

Plate  LXXIV,  Fig.  93. 
PANARITIUM  SUBCUTANEUM   (Subnitaneous  whitlow) 

Plate  LXXV,  Fig.  94. 
PANARITIUM  OSSALE  ET  ARTICULARE 

{Ossrmifi  and  ariicnlar  whitloui) 

Plate  LXX\^,  Fig.  95. 
PANARITIUM   TENDINOSUM  (Tendon-sheath  ivhithw) 

Plate  LXXVII,  Fig.  96. 
PANARITIUM  INTERDIGITALIS   (Inlerdigital  whitlow) 

Plate  LXXVII,  Fig.  97. 

Subcutaneous  suppuration  in  the  fingers  and  toes 
is  called  ivhitlow.  Although  various  forms  of  whit- 
low are  distinguished,  this  usually  begins  as  an  infec- 
tion of  the  subcutaneous  tissue  (primary  subcuta- 
neous whitlow),  from  which  may  arise  tendinous, 
periosteal,  osteal  or  articular  whitlow,  according  to 
the  extent  of  the  inflammatory  process. 

Subcutaneous  whitlows  occur  most  often  in  the 
fingers,  especially  among  the  working  classes  wlio  are 
subject  to  cracks  and  fissures  of  the  skin.  They  often 
occur  after  punctured  wounds,  through  which  staphy- 
lococci, or  more  rarely  streptococci,  gain  entrance 
to  the  subcutaneous  tissue. 

The  anatomical  formation  of  the  subcutaneous 
tissue  is  peculiar,  vertical  connective-tissue  septa  sep- 
arating the  fatty  connective  tissue  into  a  number  of 
distinct  compartments.  If  bacteria  gain  an  entry 
into  such  enclosed  chambers  the  inflammation  they 
cause  is  at  first  circumscribed. 

As  in  all  infections,  there  is  hypersemia,  exudation 
and  necrosis  of  tissue;  the  latter  occurs  rapidly,  owing 

213 


to  the  impairment  of  nutrition  from  pressure  in  the 
inflamed  area.  In  this  way  a  necrotic  core  is  formed, 
as  in  furuncle.  The  increase  of  tension  in  the  tis- 
sues causes  severe  pain,  and  the  finger  becomes  red 
and  swollen.  In  horny-handed  workmen  the  seat  of 
infection  is  at  first  difficult  to  see,  and  is  only  made 
evident  by  the  great  pain  on  pressure.  Later  on, 
when  the  suppuration  has  extended  further,  the  pain 
is  not  so  circumscribed.  In  a  few  cases  only,  the 
skin  gives  way  and  a  yellow  core  becomes  loosened 
and  cast  off,  after  which  healing  takes  place  by  gran- 
ulation tissue.  The  hard  skin  on  the  palmar  surface 
of  the  fingers  prevents  escape  of  pus,  so  that  the  latter 
takes  paths  of  less  resistance.  The  vertical  connec- 
tive tissue  septa,  mentioned  above,  direct  the  pus 
towards  the  peritendinous  tissue,  where  it  may  spread 
along  the  whole  length  of  the  tendon.  The  pus  may 
also  reach  the  loose  connective  tissue  on  the  dorsal 
surface,  and  give  rise  to  redness,  swelling  and 
oedema,  while  inflammatory  signs  may  be  absent  at 
the  seat  of  infection  on  the  flexor  surface.  If  the 
tendon  sheath  is  bathed  in  pus  for  some  time  it  be- 
comes perforated,  and  the  pus  extends  within  the 
tendon  sheath  (tendinous  whitlow,  Fig.  96).  In  the 
same  way  the  periosteum,  bony  cortex,  medullary 
cavity  and  joint  may  become  infected  from  a  sub- 
cutaneous whitlow  (Fig.  95). 

A  further  danger  of  whitlow  is  spreading  of  pus 
to  the  hand  and  forearm  along  the  tendon  sheaths. 
General  infection  may  also  occur. 

The  clinical  symptoms  vary  according  to  the  dura- 
tion and  extent  of  infection,  and  the  virulence  of  the 
bacteria.  In  sub-epidermic  whitlow  (Fig.  93),  a  puru- 
lent vesicle  develops,  generally  on  the  dorsal  surface, 
with  slight  redness  of  the  surrounding  skin.  The 
raised  epidermis  sometimes  shows  several  yellow 
spots,  where  the  pus  breaks  through.  Pain  and 
functional  disturbance  are  slight,  the  inflammation 
remaining  local.     There  is  seldom  lymphangitis,  no 

214 


tendency  to  spread,  and  little  or  no  constitutional 
disturbance. 

In  subcutaneous  whitlow  it  is  quite  otherwise 
(Fig.  94).  The  whole  finger  is  red,  swollen,  flexed 
and  extremely  painful,  especially  at  one  spot.  Red- 
ness, swelling  and  oedema  are  often  more  marked  on 
the  dorsal  surface,  together  with  lymphangitis  of  the 
hand  and  forearm.  There  is  moderate  fever  (39°  C.) 
and  some  constitutional  disturbance. 

The  symptoms  are  most  severe  in  tendinous  whit- 
low (Fig.  96).  There  is  more  swelling  of  the  finger, 
and  the  latter  is  more  flexed.  There  is  pain  on 
pressure  along  the  whole  tendon  sheath,  and  usually 
over  the  whole  palm.  Movement  of  the  tendon 
causes  great  pain,  and  extension  is  almost  impossible. 
L\Tuphangitis  and  erysipelatous  reddening  often  ex- 
tend far  beyond  the  seat  of  infection.  There  are 
rigors  and  rise  of  temperature  (40°  C),  sleepless- 
ness, and  considerable  malaise. 

If  the  tendon  sheath  of  the  thumb  or  little  finger  is 
infected,  the  pus  may  extend  along  the  course  of  these 
sheaths  as  far  as  the  wrist;  whereas,  suppuration  in 
the  tendon  sheaths  of  the  second,  third  and  fourth 
fingers  does  not  extend  beyond  the  metacarpo- 
phalangeal joints,  where  these  tendon-sheaths  end. 

In  the  wrist  the  tendon-sheaths  become  widened 
and  lie  so  close  together  that  suppuration  may 
extend  from  one  to  the  other.  In  this  way,  infection 
of  the  tendon-sheaths  of  the  thumb  may  result  from 
a  lesion  of  the  tendon  of  the  little  finger ;  and  inversely, 
infection  of  the  little  finger  from  the  thumb.  This 
has  been  called  V-shaped  whitlow.  It  is  obvious 
that  infection  of  both  tendon-sheaths  causes  severe 
symptoms — high  fever  and  much  constitutional  dis- 
turbance. The  thumb  and  little  finger  are  flexed, 
swollen  and  very  painful  on  pressure.  The  pus  often 
breaks  through  the  tendon-sheaths  and  extends 
between  the  muscles  of  the  forearm  up  to  the  elbow 
joint,  in  the  form  of  deep,  progressive  suppuration. 

215 


In  other  cases  the  wrist-joint  is  infected.  Such  cases 
may  give  rise  to  general  infection. 

The  V-shaped  whitlow  is  recognized  by  its  severe 
clinical  symptoms  and  typical  appearance.  In  the 
early  stages  there  is  often  pain,  redness  and  swelling 
in  the  palm,  or  on  the  flexor  surface  of  the  wrist. 
When  suppuration  has  existed  some  time  and  become 
extensive  it  seeks  a  way  to  the  surface.  In  this  way 
fistulas  are  formed  in  the  course  of  the  tendon- 
sheaths,  discharging  much  pus,  and  often  exposing 
the  greenish-yellow  remains  of  the  necrosed  tendon 
(Fig.  96).  The  orifices  of  these  fistulas  are  sur- 
rounded by  flabby,  unhealthy  granulations  which,  as 
mentioned  before  (Fig.  56),  indicate  necrosis  in  the 
deeper  parts. 

In  periosteal  and  osteal  whitlows,  which  generally 
occur  at  the  ends  of  the  fingers,  the  periosteum  and 
bone  are  surrounded  by  pus  and  destroyed.  In  the 
terminal  phalanx  total  necrosis  may  occur.  A  fistula 
forms  and  discharges  the  fetid,  slimy  pus,  which  is 
characteristic  of  necrosed  bone.  Eventually  dead 
bone  is  discharged.  (Fig.  95).  Parts  of  the  skin 
may  become  necrosed,  so  that,  eventually,  the  whole 
finger-joint  may  be  lost.  Commencing  with  sharp 
pain,  the  acute  stage  gradually  becomes  more 
chronic,  and  in  this  stage  infection  of  the  bones 
may  be  overlooked. 

In  the  first  and  second  phalanges  there  is  often 
infection  of  the  joints,  either  secondary  to  infection 
of  the  periosteum,  or  directly  from  the  surface. 
Articular  whitlow  generally  manifests  itself  by  rigors. 
The  joint  is  fixed  in  a  position  of  flexion  and  is  very 
painful  on  movement.  The  capsule  and  ligaments 
are  soon  destroyed,  and  destruction  of  the  cartilage 
causes  grating  on  movement.  Articular  whitlow  may 
give  rise  to  general  infection. 

It  is  not  always  easy  to  diagnose  the  stage  of  the 
whitlow.  Patients  of  the  working  class  generally 
come  so  late  for  treatment  that  there  is  often  infection 

316 


of  the  tendon-sheath,  periosteum  and  joint.  In  other 
cases  the  pain  is  so  severe  as  to  suggest  tendinous 
whitlow,  while  it  is  only  subcutaneous.  A  correct 
diagnosis  can  often  only  be  made  after  incision. 

Differential  Diagnosis.  Tuberculous  and  syph- 
ilitic inflammations  are  more  chronic  and  cause  less 
pain  and  fever.  They  do  not  heal  after  incision,  but 
require  specific  treatment. 

Treatment.  All  whitlows  require  early  incision. 
In  sub-epidermic  whitlow  the  purulent  bulla  must  be 
opened  and  dressed  with  antiseptic  dressings,  and 
the  arm  suspended  in  a  sling.  Sub-epidermic  whit- 
low may  cause  infection  of  the  deeper  tissues,  and 
there  is  also  the  danger  of  erysipelas.  Hence,  plenty 
of  dressing  should  be  used. 

Subcutaneous  whitlows  should  be  incised  as  soon 
as  possible,  under  an  anaesthetic.  Schleich's  infiltra- 
tion anaesthesia  is  dangerous  and  painful  in  infected 
areas.  However,  endoneural  injection  of  one  per 
cent,  cocaine  may  be  made  in  the  first  phalanx,  ac- 
cording to  the  method  of  Oberst-Corning,  if  there  is 
no  sign  of  inflammation  at  this  place.  But  general 
anaesthesia  should  be  employed  in  all  cases  where  the 
extent  of  the  suppuration  is  not  clear.  Incision 
should  be  made  into  the  subcutaneous  tissue  on  the 
palmar  surface  away  from  the  middle  line,  and 
between  the  joints.  The  wound  is  then  held  open 
by  retractors  and  examination  made  for  pus  in  the 
tendon-sheath  or  under  the  periosteum.  This  exam- 
ination can  only  be  made  by  a  free  incision,  after  the 
hand  is  made  bloodless  by  the  elastic  tourniquet. 

This  is  the  safest  method  of  dealing  with  whitlows; 
for  although  some  cases  may  be  cured  by  evacuation 
of  the  pus  through  a  small  incision,  suppuration  in 
the  tendon-sheath  may  be  overlooked,  and  this  may 
lead  to  spread  of  suppuration,  destruction  of  tendon, 
etc.,  and  even  death  from  general  infection. 

217 


No  doubt,  infected  wounds  of  the  finger  often  sub- 
side with  rest  in  a  shng;  but  sometimes  the  perios- 
teum is  infected,  and  this  conservative  treatment  then 
results  in  necrosis  of  the  phalanx.  Therefore,  we 
must  urge  the  treatment  of  all  such  infected  wounds 
by  early  incision,  especially  in  doctors  who  are  liable 
to  virulent  infections. 

Tendon-sheath  whitlows  require  very  careful  treat- 
ment, in  order  to  preserve  the  tendon  and  the  function 
of  the  finger.  Some  cases  come  too  late  for  treatment 
for  the  tendon  to  be  preserved.  Many  cases  of 
tendon-sheath  whitlow  extend  so  rapidly,  and  so 
often  lead  to  general  infection,  that  they  require  free 
incision  of  the  whole  area  of  suppuration.  In  some 
cases,  no  doubt,  this  may  cause  injury  to  or  loss  of 
the  tendon;  but  it  is  far  worse  to  be  responsible  for 
a  general  infection  which  might  have  been  avoided 
by  more  extensive  incision.  Therefore,  in  extensive 
tendon-sheath  whitlows,  especially  in  V-shaped  whit- 
lows, free  incisions  are  necessary,  but  these  should 
always  be  made  laterally.  In  V-shaped  whitlows 
care  must  be  taken  to  preserve  the  palmar  carpal 
ligament;  this  must  only  be  divided  when  there  is 
threatening  infection  of  the  wrist  joint,  or  extension 
of  suppuration  up  the  forearm. 

Better  functional  results  are  obtained  by  several 
smaller  incisions  instead  of  one  continuous  incision. 
Too  much  plugging  of  the  wound  is  to  be  avoided,  as 
it  interferes  with  the  nutrition  of  the  tendon.  After- 
treatment  consists  in  early  passive  movements. 

In  osteal  whitlow  necrosed  bone  must  be  removed 
if  present.  In  the  terminal  phalanx  it  is  often  suffi- 
cient to  remove  the  peripheral  end.  If  the  joint  is 
much  destroyed  resection  of  the  bone,  or  even  ampu- 
tation may  be  required. 

Progressive  suppurations,  due  to  infection  by  viru- 
lent bacteria  or  to  extensive  injuries,  must  be  freely 
laid  open,  sometimes  as  far  as  the  bone.  If  general  in- 
fection supervenes  the  question  of  amputation  arises. 

218 


Although  early  incision  removes  the  danger  of  the 
pyogenic  condition  spreading  by  subcutaneous  sup- 
puration, this  danger  may  recur  if  the  after-treatment 
is  neglected. 

The  incisions  should  be  lightly  plugged  with  iodo- 
form gauze,  which  best  absorbs  the  discharge.  After 
the  first  dressing  this  should  be  replaced  by  small 
pieces  of  sterilized  gauze,  sufficient  to  keep  the  edges 
of  the  wound  open  and  allow  the  pus  to  escape. 
The  hand  and  forearm  should  be  immobilized  on  a 
splint.  Under  this  treatment  even  deep  cavities  be- 
gin to  granulate  in  a  few  days,  when  the  plugging 
should  be  left  off  and  replaced  by  baths  and  ointment. 

To  decide  the  time  when  plugging  may  be  left  off  is 
a  matter  of  experience.  If  it  is  kept  on  too  long  the 
nutrition  of  the  tendon  (in  the  case  of  tendinous  whit- 
low) is  impaired.  If  it  is  left  off  too  soon,  suppura- 
tion may  extend  into  the  deeper  parts;  this  is  mani- 
fested by  further  redness,  swelling  and  pain,  and  by 
a  fetid,  slimy  discharge  from  the  wound  and  the  for- 
mation of  flabby,  unhealthy  granulations.  Increase 
of  pain  is  often  a  sufficient  sign  of  fresh  infection.  If 
the  extension  of  infection  is  not  immediately  noticed 
it  may  cause  severe  complications  and  general  infec- 
tion, even  during  the  period  of  after-treatment.  This 
reinfection  may  be  avoided  by  several  measures. 
First  of  all,  patients  with  severe  forms  of  whitlow 
should  be  treated  in  hospital,  where  they  can  be  kept 
under  observation  and  treated  under  more  favorable 
conditions. 

The  temperature,  in  severe  cases  of  whitlow,  should 
be  taken  every  four  hours.  The  dressings  should  be 
changed  every  day,  if  necessary  under  an  anaesthetic, 
so  that  the  local  condition  can  be  examined.  The 
gauze  tampons  should  be  carefully  removed  during 
irrigation  with  peroxide  lotion.  The  wound  should 
then  be  irrigated  with  normal  saline  solution  under 
very  slight  pressure,  and  the  dressing  renewed.  It  is 
often  necessary  to  hold  the  edges  of  the  wound  apart 

219 


by  retractors,  so  as  to  obtain  a  better  view  of  the  con- 
dition of  the  wound,  and  drain  all  suspicious  pockets. 
Drains  should  be  only  retained  after  the  first  change 
of  dressing  in  extensive  whitlows.  When  the  dressings 
are  changed  examination  must  be  made  for  inflam- 
mation and  suppuration  in  parts  remote  from  the 
wound — in  the  palm  in  tendinous  whitlow,  and  in 
the  wrist  and  elbow  joints  in  V-shaped  whitlow.  Even 
in  the  slighter  forms  of  whitlow  the  dressings  should 
be  changed  every  day,  especially  in  out-patients 
(polyclinic).  This  avoids  stiffening  of  the  fingers  by 
prolonged  immobilization,  also  the  troublesome  con- 
dition called  "glossy  skin." 

After-treatment  is  begun  when  the  suppuration  has 
ceased  and  the  temperature  has  become  normal. 
This  consists  in  performing  passive  movements  of  the 
fingers  each  time  the  dressings  are  changed.  In  out- 
patient practice  (polyclinic),  large  immobilizing  dress- 
ings should  be  applied  after  these  passive  movements 
have  been  performed.  This  is  especially  necessary  in 
alcoholic  patients,  in  whom  the  inflammation  is  much 
aggravated.  Moreover,  small  dressings  may  be  re- 
moved by  the  patient  himself.  The  application  of 
large  immobilizine;  dressings  has  a  favorable  influence 
on  the  inflammation,  and  renders  the  after-treatment 
easier  and  shorter,  while  the  disadvantage  of  immo- 
bilization is  removed  by  daily  passive  movements 
when  the  dressings  are  changed. 

In  the  treatment  of  whitlows  it  is  best  to  pursue  a 
middle  course.  On  the  one  hand,  too  large  incisions, 
too  much  plugging  and  too  long  immobilization  cause 
impairment  of  function;  on  the  other  hand,  small 
incisions,  too  little  plugging  and  too  free  movement 
may  lead  to  general  infection.  Radical  treatment  is 
best  for  the  beginner,  although  more  conservative 
methods  may  be  adopted  with  further  experience. 

After-treatment  must  be  commenced  directly  sup- 
puration has  ceased  (massage,  baths  and  passive 
movement). 

220 


Cicatricial  contractions  sometimes  yield  to  gradual 
extension;  but  some  cases  may  require  excision  of 
the  scar,  followed  by  a  plastic  operation. 

As  already  mentioned  Bier's  passive  hypersemia 
treatment  is  contra-indicated  in  acute  pyogenic  affec- 
tions; in  mild  cases  it  is  unnecessary,  and  in  severe 
cases  it  is  dangerous. 

Other  methods,  such  as  injection  of  carbolic  acid 
lotion,  staphylococcal  serum,  carbolic  and  alcoholic 
fomentations  generally  do  harm. 


221 


PANARITIUM  SUBEPIDERMOIDALE   {Subepidermis  Whitlow) 
Plate  LXXIV.  Fig.  93. 

In  this  case  a  circumscribed  redness  developed  on 
the  dorsal  surface  of  the  left  forefinger,  without  any 
obvious  injury.  This  was  followed  by  the  formation 
of  a  purulent  blister.  The  epidermis  is  raised  and 
shows  several  yellow  points  due  to  the  presence  of 
pus.  The  movement  of  the  finger  was  not  impaired. 
The  blister  was  opened,  the  pus  evacuated  and  the 
thin  epidermis  removed.  The  wound  was  dressed 
with  sterilized  gauze,  and  the  finger  put  up  on  a 
splint  extending  above  the  wrist. 


223 


Borkeiilifiiiier,  Atlas. 


Tab.  I.N\I\-. 


I'l'p.  9'i.     Panaritium  subepidennoidale. 


I'rbniaii  Conipany,  New-\'ork. 


Bockeiiliciiiier,  Alias. 


Tab.  LXXV. 


l"ig.  94.    Faiiaritiuni  subcutaneum  —  Lymphaiiyilis  acuta. 


PANARITIUM  SUBCUTANEUM  {SiibnUaneoM  Whitlow) 
Plate  LXXV,  Fig.  94. 

This  figure  shows  a  subcutaneous  whitlow,  which 
is  the  most  common  form  of  pyogenic  infection  of  the 
fingers;  according  to  von  Bergmann,  it  is  the  first 
stage  in  all  the  other  forms  of  whitlow. 

A  few  days  after  a  slight  abrasion  of  the  skin,  red- 
ness and  swelling  developed  on  the  dorsal  surface  of 
the  thumb  (the  volar  surface  is  most  commonly 
afi'ected).  This  extended  to  the  volar  side,  where 
the  color  was  paler  and  more  bluish.  There  was  also 
inflammatory  reddening  on  the  back  of  the  hand. 
As  there  was  only  slight  pain  the  patient  continued 
to  use  the  arm.  After  this  fever  and  rigors  occurred, 
with  acute  lymphangitis  extending  over  the  back  of 
the  hand  and  forearm,  and  lymphadenitis  of  the 
axillary  glands,  so  that  the  patient  could  no  longer 
use  the  finger.  At  the  seat  of  infection  the  skin 
gradually  became  thin  and  yellow,  showing  that  the 
pus  was  about  to  discharge  through  the  skin.  (In 
subcutaneous  whitlow  of  the  volar  side  this  is  pre- 
vented by  the  thickness  of  the  skin).  The  appear- 
ance of  the  lesion  at  this  time  resembled  a  furuncle. 
Above  this  there  were  several  purulent  vesicles  sur- 
rounding a  circumscribed  gangrene  of  the  epidermis 
caused  by  oedema.  Fluctuation  is  seldom  present  in 
whitlow. 

An  incision  about  half  an  inch  long  was  made  on 
the  volar  side  away  from  the  tendon.  The  wound 
was  plugged  with  iodoform  gauze.  The  lymphangitis 
was  treated  with  ointment,  and  the  whole  arm  put  on 
a  splint.  Function  of  the  finger  was  restored  in  ten 
days. 

223 


PANARIXroM  OSSALE  ET  ARTICULARE 

(Osteal  and  Articular  Whitlow) 
Plate  LXXM,  Fig.  93. 

In  this  case  a  punctured  wound  of  the  tip  of  the 
finger  was  followed  by  pain,  redness,  swelling  and 
some  fever.  It  was  treated  with  poultices.  The 
skin  gave  way  at  one  place,  forming  a  fistula  which 
discharged  fetid  pus.  Part  of  the  necrosed  phalanx 
protruded.  The  skin  above  the  fistula  became  gan- 
grenous, and  unhealthy  granulations  formed  round 
the  fistula.  Owing  to  absence  of  operative  treat- 
ment, the  suppuration  extended  to  the  joint  and 
destroyed  ligaments,  capsule  and  cartilage,  so  that 
the  function  of  the  joint  was  destroyed.  After  further 
treatment  with  fomentations,  the  whole  finger  be- 
came swollen  and  the  skin  assumed  a  pale,  glistening 
appearance  (glossy  skin),  indicating  necrosis  of  the 
whole  basal  phalanx. 

Under  an  anaesthetic  an  incision  was  made,  and 
the  first  and  second  phalanges  were  found  to  be  so 
much  destroyed  that  they  were  removed. 

As  already  mentioned,  punctured  wounds  of  the 
terminal  phalanx,  beyond  the  insertion  of  the  tendon, 
often  lead  to  infection  of  the  periosteum.  Commenc- 
ing in  acute  inflammation  with  pain  and  swelling, 
they  often  assume  a  more  chronic  condition.  If  an 
incision  is  not  made  in  the  acute  stage  there  may  be 
extensive  destruction,  even  of  the  whole  finger; 
especially  after  treatment  with  poultices.  In  the 
above  case  an  early  incision  would  have  saved  the 
finger  and  restored  normal  function. 

"Glossy  skin"  (Paget)  is  a  condition  which  affects 
chiefly  the  phalanges  of  the  fingers,  after  badly  cov- 

224: 


Bockenheimer,  Atlas. 


Tab.  I.XXVI. 


Fig.  95.     I'anaritium  ossale  et  articulare. 


Rebman  Company,  New- York. 


ered  amputation  stumps,  or  after  too-long  immo- 
bilization. This  condition  may  extend  over  the  whole 
finger.  The  skin  is  at  first  thickened,  bluish  red, 
and  cold  to  the  touch;  later  on  it  becomes  pale  yel- 
low and  has  an  appearance  like  parchment.  The  cir- 
culation is  bad  and  there  are  often  neuralgic  pains 
and  a  feeling  of  coldness.  It  may  finally  lead  to  trau- 
matic neurasthenia.  This  condition  can  be  pre- 
vented by  avoiding  too  long  immobilization  and  by 
providing  the  amputation  stumps  with  sufficient  well- 
nourished  flaps. 


225 


PANARITIUM  TENDINOSUM   (Tendincms  Whitlow) 
Plate  LXXMI,  Fig.  96. 

This  is  a  case  of  subcutaneous  whitlow,  following 
a  punctured  wound,  which  rapidly  spread  to  the 
tendon-sheath  of  the  thumb.  A  severe  form  of 
infection  was  indicated  by  the  acute  redness  and 
swelling,  severe  pain,  high  temperature  and  consti- 
tutional disturbance.  As  no  incision  was  made,  the 
tei'minal  phalanx  continued  to  swell  and  finally  gave 
way,  forming  a  fistula  discharging  pus  and  parts  of 
necrosed  tendon.  Apart  from  this,  the  diagnosis  of 
tendinous  whitlow  could  be  made  from  the  severity 
of  the  symptoms;  from  the  complete  loss  of  move- 
ment in  the  thumb,  the  great  pain  on  pressure  over 
the  course  of  the  tendon,  the  swelling  and  redness  of 
the  ball  of  the  thumb,  and  the  discharge  of  pus  from 
the  fistula  on  pressure  over  this  part.  The  tendon 
sheath  of  the  little  finger  was  unaffected,  and  there 
was  no  sign  of  abscess  above  the  wrist. 

Under  an  anaesthetic  an  incision  was  made  along 
the  whole  of  the  terminal  phalanx  and  pus  evacuated 
from  the  tendon-sheath.  A  second  incision  was 
made  in  the  palm,  a  little  below  the  wrist,  and  the 
tendon-sheath  opened  again  at  this  point.  By  this 
means  the  suppuration  ceased  and  infection  of  the 
tendon-sheath  of  the  little  finger  was  avoided.  As  the 
tendon  of  the  thumb  was  already  partly  destroyed, 
the  end  joint  remained  functionless.  In  spite  of  a 
certain  degree  of  contracture,  the  patient  could 
use  the  thumb,  by  movement  at  the  metacarpo- 
phalangeal joint. 


236 


Bockenheimer,  Atlas. 


Tab.  I.XXVIL 


ti3 


o 

n 

c 


o 
So 


D»kni.*«     r^ 


M...»    V'».-l. 


PHLEGMONE  INTERDIGITALIS  {Interdigiial  Whitlow) 
Plate  LXXVIl,  Fig.  97. 

This  term  is  applied  to  subcutaneous  suppuration 
between  the  metacarpal  bones.  In  Fig.  97  this 
occurred  between  the  metacarpal  bones  of  the  thumb 
and  index  finger.  Redness  and  oedema  appeared  on 
the  dorsal  surface  and  movement  of  the  fingers  was 
painful.  In  these  cases  there  is  usually  some  fever, 
but  no  lymphangitis  or  constitutional  disturbance. 
As  the  amount  of  pus  is  usually  considerable,  there  is 
fluctuation.  The  pus  was  evacuated  by  a  dorsal 
incision  (incision  on  the  palmar  side  is  to  be  avoided) ; 
the  wound  was  plugged  for  a  short  time  and  the  arm 
suspended  in  a  sling.  Complete  function  was  restored. 

Early  incision  prevents  spreading  of  suppuration  to 
the  palm.  Interdigital  whitlow  in  the  palm  is  dis- 
tinguished from  tendon-sheath  whitlow  by  there 
being  less  pain  on  movement  of  the  fingers,  and  less 
tenderness  on  pressure  over  the  tendons. 


227 


PARONYCHIA   (Pen-ungual  Whitlow) 
Plate  LXXVIII,  Fig.  98. 

Inflammation  of  the  tissues  under  the  nail  is  called 
suh-ungual  wJdtloiv.  Owing  to  pressure  of  the  nail, 
the  virulence  of  the  infecting  bacteria  is  increased,  so 
that  the  inflammation  extends  rapidly  and  soon  leads 
to  necrosis  of  the  tissues.  Sub-ungual  whitlow  causes 
severe  pain  and  lymphangitis.  It  is  often  overlooked, 
as  the  changes  under  the  nail  are  not  at  first  visible, 
and  the  first  sign  is  usually  a  yellow  coloring  seen 
under  the  nail.  The  diagnosis  is  suggested  by  the 
severe  pain  on  pressure  on  the  nail.  As  the  pus  can- 
not break  through  the  nail,  it  extends  deeply  and  may 
cause  necrosis  of  the  terminal  phalanx  by  infection  of 
the  periosteum.  Clavi  and  exostoses  may  also 
develop  under  the  nail  and  cause  inflammation  with 
severe  pain.  Under  local  anaesthesia  the  nail  may 
be  pared  down  with  a  knife,  so  that  the  inflammatory 
area  can  be  incised.  If  suppuration  is  extensive  the 
nail  must  be  removed. 

When  the  inflammation  is  not  under  the  nail  but 
around  the  nail  bed,  the  condition  is  called  pcri- 
ungval  whitlow  or  paronychia.  This  may  be  caused 
by  punctured  wounds,  tearing  of  the  nail,  foreign 
bodies,  or  by  manicure  with  dirty  instruments.  The 
bed  of  the  nail  is  red,  infiltrated  and  painful  on  pres- 
sure. There  is  often  suppuration  round  the  nail, 
which  is  raised  from  its  bed  and  may  become  quite 
loose.  In  severe  cases  there  is  much  pain,  fever  and 
lymphangitis. 

Differential  Diagnosis.  Syphilitic  chancre  of 
the  finger  often  resembles  paronychia.     It  begins  with 

228 


Bockenheimer,  Atlas. 


Tah.  I.X.W; 


CO 


W) 


W.,,    \'^..t. 


redness  and  hard  infiltration  which  develops  into  an 
unhealthy  ulcer  with  flabby  granulations.  This  is 
followed  by  painful  infiltration  of  the  lymphatic  ves- 
sels and  glands.  This  form  of  chancre  is  very  chronic 
and  painful  (thus  dift'ering  from  most  other  chancres). 
Syphilitic  chancre  should  be  borne  in  mind  in  every 
case  of  chronic  paronychia  which  is  refractory  to 
treatment.  It  is  especially  common  in  medical  men 
and  midwives. 

Tuberculous  infection  of  the  nail  bed  may  also 
occur  among  doctors  and  nurses.  This  begins  in  a 
dark-red  infiltration  of  the  skin.  Nodules  then 
develop  and  break  down  into  an  ulcer  with  flat, 
irregular  borders.  The  tuberculous  granulations  are 
grayish  red  and  bleed  easily.  This  affection  is  very 
chronic.  The  nail  may  be  lost  and  replaced  by 
thickened  tissue  in  both  tuberculous  and  syphilitic 
paronychia.  In  some  cases  the  whole  finger  may  be 
destroyed.  The  diagnosis  of  tuberculous  paronychia 
can  sometimes  only  be  settled  by  microscopic  exami- 
nation, or  by  inoculation  of  the  guinea  pig.  The 
diagnosis  of  syphilitic  chancre  is  confirmed  by  find- 
ing the  spirochacta  pallida  in  scrapings. 

Treatment.  In  peri-ungual  whitlow  or  paronychia 
an  early  incision  should  be  made,  before  the  pus  has 
loosened  the  nail.  It  is  best  to  make  a  horseshoe 
incision  through  the  soft  parts  some  distance  from 
the  nail,  to  avoid  interfering  with  its  nutrition.  The 
hand  should  be  immobilized  for  a  few  days.  If  the 
nail  is  extensively  separated  it  must  be  removed. 

Tuberculous  paronychia  requires  treatment  by  the 
sharp  spoon  or  Paquelin's  cautery.  Syphilitic  chan- 
cre must  be  treated  by  mercury. 

Fig.  98  shows  acute  inflammatory  infiltration 
round  the  nail.  The  skin  is  bluish  red  and  tender 
to  the  touch.  Under  local  anaesthesia  a  horseshoe 
incision  was  made  through  the  infiltrated  tissue. 
Healing  took  place  with  preservation  of  the  nail. 

229 


UNGUIS   mCARNATUS   (Ingromng  toenail) 
Plate  LXXVIII,  Fig.  99. 

Ingrowing  toenail  aflPects  almost  exclusively  the 
nail  of  the  great  toe;  generally  the  outer  side,  less 
often  the  inner  side,  occasionally  both  sides.  It  gives 
rise  to  severe  inflammation  of  the  soft  parts  next  the 
border  of  the  nail;  first  redness  and  swelling,  after- 
wards ulceration  and  granulation  tissue.  The  in- 
flammation is  usually  limited  to  a  small  area,  but  may 
sometimes  spread  over  the  whole  nail-bed.  The 
affection  causes  considerable  pain  and  often  pre- 
vents the  patient  from  walking.  There  may  be 
lymphangitis.  If  both  sides  of  the  nail  are  afi^ected 
the  symptoms  are  naturally  more  severe.  Ingrowing 
toenail  often  occurs  in  connection  with  hallux  valgus 
(Fig.  64) ;  it  may  also  be  caused  by  anomalies  of  the 
nails  or  toes,  by  wearing  too  short  boots,  or  by  cutting 
the  nails  too  much  at  the  sides. 

Differential  Diagnosis.  Subungual  clavus  or 
exostosis  may  cause  inflammation  round  the  nail, 
but  in  these  cases  the  nail  is  always  raised  in  front 
and  is  very  tender  to  pressure.  Syphilitic  chancre  has 
also  been  known  to  occur  on  the  great  toe,  after  suck- 
ing the  toe  (Bockenheimer). 

Treatment.  Ingrowing  toenail  may  be  avoided 
by  prophylactic  treatment.  The  toenails  should  be 
cut  straight  and  not  too  short,  so  that  the  free  border 
extends  beyond  the  soft  parts,  especially  at  the  sides. 
Attention  should  be  paid  to  cleanliness  and  to  the 
wearing  of  properly  made  boots.  In  slight  cases  the 
edge  of  the  nail  may  be  raised  from  the  inflamed  soft 

230 


parts  by  an  iodoform  tampon,  or  partial  excision  of 
the  nail  may  be  performed.  In  severe  cases  these 
methods  are  useless.  Excision  of  the  nail,  which  was 
formerly  practiced,  is  useless,  as  the  condition  recurs 
after.  The  most  rational  method  consists  in  excision 
of  the  whole  lateral  border  of  the  nail  together  with 
the  inflamed  soft  parts,  down  to  the  bone;  taking 
care  to  include  the  posterior  part  of  the  matrix,  so 
that  recurrence  cannot  take  place.  The  woiuid  is 
dressed  with  iodoform  powder  and  sterilized  gauze 
and  immobilized  for  a  week,  after  which  the  wound 
is  usually  healed.  In  ingrowing  toenail  affecting 
both  sides  the  same  operation  is  performed  on  each 
side,  leaving  the  center  part  of  the  nail  in  place. 

Fig.  99  shows  an  ingrowing  toenail  on  the  outer 
side  of  the  right  great  toe.  The  thickened  soft  parts 
have  grown  over  the  border  of  the  nail.  There  is  a 
purulent  discharge  from  unhealthy  granulations.  The 
nail  is  so  imbedded  in  the  swollen  soft  parts  that  it  is 
only  partly  visible.  The  above  operation  was  per- 
formed with  good  result. 


231 


CLAVUS   nOi'LAMMATORrUS  (Inflammatory  Clavus)  (Com) 
Plate  LXXIX.  Fig.  100. 

The  figure  shows  an  inflammatory  condition  affect- 
ins  the  whole  of  the  second  toe  and  extendiuo;  to  the 
dorsum  of  the  foot.  The  skin  on  the  dorsal  surface 
of  the  toe  was  at  first  raised  by  purulent  vesicles. 
After  these  had  broken,  the  necrosed  epidermis  came 
away,  exposing  a  considerable  extent  of  the  corium. 
The  redness  and  swelling  are  most  marked  over  the 
first  interphalangeal  joint,  which  was  very  painful  on 
movement.  On  the  dorsal  side  of  the  joint  fluctua- 
tion was  present.  The  remains  of  a  clavus  (corn) 
are  seen  on  the  great  toe,  in  the  form  of  a  yellowish- 
white  projection,  together  with  a  fistula  leading  to 
the  deeper  parts.  The  clavus  on  the  second  toe  was 
due  to  its  being  exposed  to  pressure  from  its  crooked 
position. 

Clavi,  or  corns,  are  circumscribed  growths  which 
arise  from  the  horny  layer  of  the  epidermis.  They 
generally  occur  on  the  great  and  little  toes;  some- 
times between  the  toes,  especially  when  these  are 
crooked  owing  to  bad  boots.  They  also  occur  in  con- 
nection with  hallux  valgus,  hammer-toe,  club-foot, 
etc.  The  more  they  project  above  the  level  of  the 
skin  the  more  painful  they  are  to  pressure.  They 
differ  from  the  diffuse,  horny  thickenings  which  occur 
on  the  hands,  and  consist  in  a  circumscribed  horny 
formation  which  develops  from  a  soft  conical  core 
situated  in  the  depth  of  the  cutis.  When  the  horny 
layer  is  removed  the  soft  yellowish-white  core  is  seen 
in  the  center.  Lacerations  caused  by  unskillful  cut- 
ting of  corns  may  easily  give  rise  to  subcutaneous 
abscess.     Underneath   large   clavi   there   is   usually 

232 


Bockenheimer,  Atlas. 


Tab.  I.XXIX. 


•a 
<u 

he 

o 


3 


o 
o 


Kcbman  Comnanv.  Neip-\'ork-. 


develoj)ed  a  bursa,  which  is  Hable  to  become  inflamed 
from  external  pressure.  The  inflammatory  exuda- 
tion from  the  bursa  generally  discharges  by  a  fistula 
near  the  clavus  (Fig.  100).  Septic  infection  of  the 
bursa  may  be  caused  through  the  fistula,  and  this  may 
extend  to  the  neighboring  tendon-sheath  or  joint. 
Joint  infection  is  especially  frequent  when  the  bursa 
communicates  with  the  joint;  and  is  manifested  by 
severe  local  inflammation,  fever,  rigors  and  constitu- 
tional disturbance.  The  purulent  arthritis  may  even 
give  rise  to  general  infection. 

Treatment.  Prophylactic  treatment  of  clavus 
consists  in  cleanliness  and  the  wearing  of  proper 
boots.  If  a  clavus  forms  it  should  be  removed  with 
a  sterilized  knife.  It  is  not  sufficient  to  remove  the 
horny  layer;  the  deeply  situated  core  must  also  be 
removed,  otherwise  recurrence  takes  place.  Other 
methods,  such  as  the  application  of  salicylic  collo- 
dion, only  loosen  the  horny  layer  and  do  not  prevent 
recurrence. 

If  a  bursa  forms  under  the  clavus  it  must  either  be 
incised  and  plugged,  or  excised.  If  suppuration 
extends  to  the  joint  this  must  be  opened;  in  some 
cases  resection  or  disarticulation  may  be  necessary. 

In  Fig.  100  there  was  inflammation  of  a  bursa 
which  communicated  with  the  joint.  The  bursa 
discharged  through  a  fistula,  and  infection  through 
the  fistula  gave  rise  to  suppuration  and  to  inflamma- 
tion of  the  joint.  Severe  sjTQptoms  developed,  with 
rigors  and  fever,  and  lymphangitis  of  the  foot  and 
leg.  The  joint  was  opened  on  the  dorsal  surface  by 
a  transverse  incision,  and  the  superficial  suppuration 
by  another  incision  on  the  dorsum  of  the  foot.  The 
clavus  and  the  bursa  were  excised  subsequently. 


233 


PHLEGMONE  PROGREDIENS  PUTRIDA 

(Putrejadive  Phlegmon) 
Plate  LXXIX,  Fig.  101. 

Pyogenic  affections  are  especially  dangerous  when 
the  infection  is  caused  by  very  virulent  bacteria,  and 
also  when  bacteria  invade  a  debilitated  body  {e.g. 
diabetes).  In  this  case  (Fig.  101),  subcutaneous  sup- 
puration, following  a  slight  wound  of  the  great 
toe,  rapidly  spread  to  the  tendon-sheath  and  the 
joint,  necessitating  amputation  of  the  toe  on  account 
of  the  extensive  infection  and  severe  constitutional 
symptoms.  Although  the  operation  was  made 
through  tissues  not  yet  inflamed,  further  suppuration 
occurred  on  the  sole  of  the  foot,  which  spread  rapidly 
and  destroyed  the  soft  parts,  tendons,  muscles  and 
fascia,  and  infected  the  metacarpal  bones.  The 
severity  of  the  inflammation  is  shown  by  the  great 
swelling  around  the  metacarpus.  This  is  not  a  case 
of  the  progressive  suppuration  which  is  common  in 
diabetes,  but  one  of  secondary  infection  by  bacteria 
of  putrefaction,  giving  rise  to  a  putrid,  sanious  inflam- 
mation. If  pyogenic  and  putrefactive  phlegmons  are 
combined,  there  is  not  only  rapid  necrosis  of  all  the 
tissues  with  extension  of  the  process  to  the  neigh- 
boring parts,  but  also  general  infection  (cf.  Fig.  108). 

The  appearance  of  the  wound  in  this  form  of  in- 
flammation, which  is  also  called  gangrenous,  is 
characteristic.  Owing  to  the  fibrinous  exudation, 
the  wound  is  coated  with  a  diphtheroid  membrane. 
This  condition  has  been  called  "wound  diphtheria"; 
but  it  is  better  to  use  the  term  diphtheroid,  as  cases 
of  true  infection  of  wounds  with  diphtheria  bacilli  are 
rare.    In  putrefactive  phlegmon  dry,  unhealthy  granu- 

234 


lations  are  present  along  with  the  diphtheroid  mem- 
brane. There  is  also  a  sanious,  fetid,  dirty  discliarge 
from  the  wound,  containing  numerous  pieces  of 
necrosed  tissue.  Similar  conditions  are  found  in 
wounds  in  general  infection. 

In  diabetics,  these  putrefactive  phlegmons  assume  a 
very  extensive  and  dangerous  character,  as  the  dia- 
betic tissues  constitute  a  favorable  nutritive  medium 
for  bacteria,  especially  those  of  putrefaction,  while 
the  debilitated  body  offers  little  resistance  to  them. 
If  an  incision  is  made  in  these  cases  all  the  tissues  are 
seen  to  be  bathed  in  a  dirty  green  fluid  and  in  a  state 
of  necrosis,  often  consisting  only  of  yellowish-green 
necrotic  shreds.  The  skin,  fascia,  muscles  and  ten- 
dons are  the  first  to  be  destroyed,  while  the  bones 
resist  longer.  In  our  case,  the  pyogenic  and  putrefac- 
tive phlegmon  had  already  loosened  the  periosteum 
from  the  bones  and  caused  infection  of  the  cortex 
and  medullary  cavity  (osteomyelitis,  cf.  Fig.  104). 
The  infection  of  the  bones  at  first  gave  rise  to  severe 
rigors,  but  afterwards  assumed  a  more  chronic  form 
of  inflammation.  There  was  also  extensive  lymphan- 
gitis and  thrombo-phlebitis  of  the  leg. 

Treatment.  In  cases  of  putrefactive  phlegmon, 
free  incisions  must  be  made  in  the  diseased  tissues  as 
early  as  possible,  as  general  infection  often  occurs 
rapidly  from  the  action  of  toxins.  If  the  process 
continues  to  extend  in  spite  of  the  incisions,  amputa- 
tion through  healthy  tissues  must  not  be  delayed  too 
long;  otherwise  the  patient  will  succumb  in  spite  of 
amputation. 

In  the  phlegmonous  inflammations  occurring  in 
diabetes,  which  often  begin  in  the  toes  and  spread 
destruction  over  the  whole  foot  in  a  few  hours,  the 
conditions  are  especially  complicated.  If,  after  exten- 
sive incisions,  the  temperature  does  not  immediately 
fall,  amputation  must  be  performed;  otherwise  gen- 
eral  infection   will   occur  ra{>idly.     In   any  case   of 

235 


phlegmonous  inflammation  in  a  diabetic  patient  death 
may  occur  from  coma  or  heart  failure. 

In  Fig.  101  there  was  a  combination  of  pyogenic 
and  putrefactive  phlegmon  of  a  progressive  character 
in  a  diabetic  patient.  High  temperature,  rigors,  dry 
tongue  and  somnolence  suggested  the  commence- 
ment of  general  infection.  Amputation  was  performed 
above  the  knee,  owing  to  the  presence  of  lymphan- 
gitis, thrombo-phlebitis  in  the  leg,  and  also  advanced 
arterio-sclerosis.  The  operation  was  performed  un- 
der lumbar  anaesthesia  and  led  to  healing. 


236 


Bockenheimer,  Atlas. 


Tab.  LXXX. 


I'l'^.  102.     I'lilcgmone  colli   —   Phlegmon  ligneu.x. 


PHLEGMONE  COLLI  (PJikgman  of  the  neck) 
riate  LXXX,  Fig.  102. 

In  the  region  of  the  neck,  subcutaneous  and  sub- 
fascial phlegmons  are  common,  owing  to  the  numerous 
groups  of  lymphatic  glands  in  this  situation.  Suppu- 
rative inflammation  of  these  glands  may  be  caused 
by  affections  of  the  mouth  and  pharynx,  carious 
teeth,  angina,  otitis  media,  alveolar  periostitis,  foreign 
bodies,  etc.  Eczema  and  other  affections  of  the  head 
and  face  may  also  cause  suppuration  in  the  glands  of 
the  neck,  especially  in  young  individuals.  The  infec- 
tion is  generally  due  to  staphylococci,  sometimes 
streptococci  and  other  bacteria.  In  lesions  of  the 
mouth  and  pharynx  putrefactive  bacteria  are  some- 
times found  in  the  buccal  cavity. 

Subcutaneous  phlegmon  in  the  neck  manifests 
itself  by  redness  of  the  skin,  inflammatory  infiltration 
and  fever;  later  on  fluctuation  can  be  made  out.  In 
nearly  all  cases  a  circumscribed  abscess  forms  on  one 
side  of  the  neck.  Large  abscesses  may  cause  dysp- 
noea by  pressure  on  the  larynx,  and  dysphagia  by 
pressure  on  the  esophagus. 

In  the  submaxillary  region  the  inflammation  oc- 
curs most  commonly  in  the  subcutaneous  l;yTnphatic 
glands,  and  the  abscess  is  situated  outside  the  cap- 
sule of  the  submaxillary  gland.  This  must  be  dis- 
tinguished from  intracapsular  suppuration  of  the 
submaxillary  gland  itself,  which  is  called  Ludwig's 
angina  (angina  Ludovici).  In  this  case  the  symp- 
toms are  much  more  severe— fever,  rigors,  swelling 
in  the  buccal  cavity  and  pharj'nx,  causing  difficulty 
in  respiration  and  swallowing. 

Infection  of  the  sub-mental  honphatic  glands  gives 

237 


rise  to  an  abscess  in  the  middle  line.  These  cases  are 
rare,  and  generally  due  to  lesions  of  the  lower  lip. 

Deep  suppurations  in  the  neck,  under  the  fascia, 
arise  from  the  deep  lymphatic  glands.  They  occur 
after  lesions  in  the  pharynx,  esophagus  and  larynx, 
also  after  tonsilitis  and  scarlet  fever,  and  are  more 
dangerous  on  account  of  their  deep  situation.  They 
develop  with  fever  and  rigors,  and  diffuse  inflamma- 
tory infiltration  in  the  neck,  while  the  deep  suppura- 
tion can  seldom  be  detected  by  fluctuation.  This 
deep  suppuration  manifests  itself  by  cyanosis  of  the 
face,  oblique  position  of  the  head,  trismus  of  the 
jaw,  attacks  of  asphyxia  and  diflSculty  in  swallow- 
ing. The  pus  may  make  its  appearance  in  the 
supraclavicular  fossa  or  in  the  axilla. 

In  some  cases  (especially  in  streptococcal  infection) 
there  is  no  formation  of  pus,  but  a  dirty,  fetid,  green- 
ish fluid  which  infiltrates  all  the  tissues.  Such  cases 
often  lead  to  general  infection.  Diffuse  inflammation 
may  also  occur  after  operations  on  the  neck,  larynx 
and  esophagus,  and  cause  death  by  extension  to  the 
mediastinum. 

The  term  "wooden  phlegmon"  (phlegmon  lig- 
neux)  is  given  to  a  chronic  inflammation  of  the 
neck,  which  gives  rise  to  an  infiltration  of  wooden 
hardness,  often  extending  over  the  whole  neck,  with 
slight  inflammatory  symptoms.  The  skin  is  slightly 
blue,  cedematous,  and  pits  on  pressure.  There  is  no 
fever  nor  pus  formation.  The  infiltration  may  cause 
dyspnoea  by  pressure  on  the  larynx.  When  incised, 
a  dirty,  greenish-yellow  fluid  is  seen  in  the  subcuta- 
neous, subfascial  and  inter-muscular  tissues,  extend- 
inor  throuarh  the  whole  refrion  of  the  neck.  This 
affection  often  occurs  in  old  and  cachectic  people 
after  lesions  of  the  mouth  and  pharynx,  probably 
from  infection  by  bacteria  of  slight  virulence. 

Differential  Diagnosis.  This  has  to  be  made 
from  alveolar  periostitis  (Fig.  104),  osteomyelitis  of 

238 


the  lower  jaw  (Fio;.  105),  tuberculous  adenitis,  and 
cystic  tumors  in  the  neck  (blood  cysts,  dermoids 
sebaceous  cysts,  branchial  cysts).  Changes  in  the 
bone  are  revealed  by  an  incision  in  the  case  of 
periostitis  and  osteomyelitis.  Acute  symptoms  and 
fever  are  absent  in  the  other  formations,  but  sujjpu- 
ration  of  a  cystic  tumor  may  resemble  glandular  sup- 
puration. In  cases  of  deep  suppuration  in  the  neck, 
retro-phar^Tigeal  abscess  must  be  borne  in  mind. 

Wooden  phlegmon  of  the  neck  may  be  mistaken 
for  commencing  actinomycosis,  but  the  latter  soon 
gives  rise  to  a  fistula  vi'hich  discharges  pus  mixed  with 
the  characteristic  yellow*  bodies  (Fig.  115). 

Treatment.  Poultices  are  contra-indicated,  as 
they  cause  considerable  destruction  of  tissue,  and 
allow  the  right  time  for  incision  to  be  passed  by. 
Early  incision  is  indicated  in  most  cases.  In  sub- 
cutaneous phlegmons  with  a  tendency  to  become 
circumscribed,  incision  should  not  be  made  until  an 
abscess  forms.  Under  local  anaesthesia  an  incision 
is  made  through  the  skin  at  the  lowest  part  of  the 
abscess,  and  the  pus  evacuated  by  means  of  blunt 
dressing  forceps.  In  the  submaxillary  region  the 
facial  nerve  and  vessels  must  be  avoided. 

In  intracapsular  inflammation  of  the  submaxillary 
gland,  the  gland  must  be  freely  incised  before  sup- 
puration occurs,  otherwise  general  infection  may 
occur  from  increased  virulence  of  the  bacteria  due 
to  pressure  of  the  capsule. 

In  all  cases  of  phlegmons  in  the  neck  in  which 
there  is  much  infiltration  of  the  floor  of  the  mouth 
with  difficulty  in  breathing  and  swallowing,  it  is 
advisable  to  perform  a  preliminary  tracheotomy,  as 
death  may  occur  from  sudden  oedema  of  the  glottis 
during  anaesthesia. 

In  deep  suppurations  of  the  neck  we  must  not  wait 
for  the  appearance  of  a  superficial  abscess.  A  free 
incision  must  be  made  along  the  median  border  of 

239 


the  sternomastoid  muscle.  Extensive  cases  require 
counter-incisions.  The  wounds  should  be  drained 
by  gauze  tampons,  as  drainage  tubes  may  injure  the 
large  vessels. 

Wooden  phlegmon  of  the  neck  sometimes  requires 
multiple  deep  incisions,  laterally  and  in  the  middle 
line. 

Fig.  102  shows  acute  inflammation  of  the  sub- 
maxillary lymphatic  glands,  with  the  formation  of 
an  abscess  under  the  skin.  It  was  treated  under 
local  anaesthesia  by  incision  and  drainage. 


240 


Bockeiilieimer,  Atlas. 


Tab.  LXXXI. 


rig.  103.    Periostitis  alveoians  innulciita  —  Parulis. 


r>„i ..   r*^. „«„...,     \i«,».  \'^^i. 


PERIOSTITIS  ALVEOLARIS  PURULENTA— PARULIS 

(Purulent  alveolar  Periostitis) 
Plate  LXXXI,  Fig.  103. 

Parulis  i.s  a  name  given  to  purulent  alveolar  perios- 
titis of  the  lower  jaw,  which  usually  gives  rise  to  a 
subcutaneous  abscess.  It  may  be  caused  by  lesions 
of  the  gums  (e.g.  after  tooth-extraction  with  dirty 
instruments),  fractures  of  the  jaw,  operations  on  the 
jaw,  caries  of  the  teeth,  fistulas  from  the  stumps  of 
teeth.  Infection  of  the  periosteum  of  the  alveolar 
portion  of  the  lower  jaw  gives  rise  to  a  circumscribed 
subperiosteal  accumulation  of  pus  which  descends 
to  the  submaxillary  region  and  lies  over  the  fascia 
covering  the  submaxillary  gland.  The  signs  of  puru- 
lent inflammation  are  most  apparent  in  this  region, 
while  symptoms  at  the  seat  of  infection  are  often  slight. 

The  symptoms  commence  with  fetor  of  the  breath, 
fever  and  rigors,  and  inflammatory  infiltration  in  the 
submaxillary  region.  Soon  afterwards  the  presence 
of  fluctuation  indicates  abscess  formation,  after  which 
the  symptoms  diminish.  In  most  cases  the  suppu- 
ration is  circumscribed,  but  sometimes  there  is  dift'use 
inflammation,  causing  considerable  infiltration  of  the 
soft  parts  and  swelling  and  redness  of  the  side  of  the 
face.  There  is  then  often  trismus  and  oedema  of  the 
mucous  membrane  of  the  mouth,  with  difficulty  in 
mastication  and  often  difficulty  in  breathing.  In 
these  diffuse  forms  there  are  severe  constitutional 
symptoms — rigors,  fever,  headache,  etc. 

Although  the  circumscribed  form  is  harmless,  the 
diffuse  form  may  be  dangerous  to  life,  especially 
when  improperly  treated.  Treatment  of  the  circum- 
scribed form  by  poultices  may  give  rise  to  the  diffuse 
form.     If  the  pus  is  allowed  to  remain  for  long  under 

241 


the  periosteum,  it  may  cause  osteomyelitis  of  the 
jaw  and  all  its  consequences  (Fig.  104).  Meningitis 
and  general  infection  may  also  occur  from  thrombo- 
phlebitis. 

In  the  upper  jaw,  infection  of  the  periosteum  may 
also  cause  subperiosteal  suppuration,  which  has  not 
such  favorable  conditions  for  extension  to  the  sub- 
cutaneous tissue  as  in  the  case  of  the  lower  jaw. 
Small  abscess  caused  by  morbid  conditions  of  the  teeth 
may  burst  into  the  mouth  and  cause  no  trouble,  but 
more  virulent  infection  may  cause  osteomyelitis  of 
the  upper  maxilla,  which  rapidly  extends  over  the 
whole  of  the  bones  of  the  face,  and  often  causes 
death  by  general  infection.  In  these  cases  there  is 
infiltration  of  the  upper  part  of  the  face,  oedema  of 
the  eyelids,  high  temperature,  rigors,  headache,  etc. 

In  these  morbid  conditions  pyogenic  inflammation 
generally  staphylococcal,  is  often  combined  with 
putrefactive  inflammation  from  bacteria  in  the 
mouth.  We,  therefore,  find  the  fetid,  dirty,  reddish- 
brown  pus,  mixed  with  broken-down  tissue,  which  is 
characteristic  of  putrefactive  inflammation. 

Differential  Diagnosis.  Although  parulis  of  the 
lower  jaw  may  cause  swelling  of  the  neck  resembling 
glandular  abscess,  it  can  usually  be  distinguished  by 
the  history,  and  by  inspection  of  the  mouth.  If  the 
parulis  has  been  present  some  time  the  bone  becomes 
to  a  considerable  extent  denuded  of  its  periosteum 
which  distinguishes  it  from  glandular  abscess.  In 
the  upper  jaw  empyema  of  the  antrum  of  Highmare 
may  be  mistaken  for  parulis,  especially  when  the 
empyema  has  broken  through  the  bony  wall  of  the 
antrum  and  appears  as  an  abscess  under  the  gum. 
If  the  antrum  of  Highmare  is  translucent  to  light 
there  is  no  pus  in  it;  on  the  other  hand,  absence  of 
translucency  does  not  necessarily  indicate  the  pres- 
ence of  pus,  as  this  sometimes  occurs  in  the  normal 
condition. 

243 
I 


Primary  acute  osteomyelitis  commences  with  more 
severe  symptoms — high  fever,  frequent  rigors,  etc. 

Treatment.  Circumscribed  abscesses  should  be 
incised  under  local  antesthesia.  Poultices  are  to  be 
avoided.  Diffuse  inflammations  should  be  incised 
under  general  anaesthesia  before  the  formation  of 
abscess.  By  this  means  the  above-mentioned  com- 
plications may  be  prevented.  In  parulis  of  the  lower 
jaw  an  incision  should  be  made  through  the  skin 
and  the  pus  evacuated  by  dressing  forceps;  in  this 
way  pus  can  be  found  which  was  not  apparent  from 
the  external  appearance.  If  the  rough  bone  is  found 
a  large  drainage  tube  should  be  inserted.  The  inci- 
sion should  be  made  about  three-fourths  inch  below 
the  border  of  the  jaw  to  avoid  the  branches  of  the 
facial  nerve  which  supply  the  muscles  at  the  angle 
of  the  mouth. 

In  the  upper  jaw  operation  should  be  performed 
from  the  mouth ;  with  the  head  hanging  low,  in  cases 
of  large  accumulations  of  pus. 

In  all  cases  of  parulis  the  teeth  must  be  attended 
to;  carious  teeth  and  stumps,  which  have  given  rise 
to  the  condition,  should  be  removed.  Drains  and 
tampons  can  be  left  out  in  a  few  days,  when  suppu- 
ration has  ceased.  If  the  movements  of  the  jaw  are 
limited,  fluid  diet  may  be  necessary  at  first. 

Fig.  103  shows  a  case  of  parulis  arising  from  a 
carious  premolar  of  the  lower  jaw.  It  began  with 
pain  and  fever,  and  the  formation  of  an  abscess 
under  the  gum.  Eventually,  an  abscess  formed  in 
the  neck,  after  which  the  symptoms  subsided.  Under 
general  an:esthesia  an  incision  an  inch  long  was  made 
at  the  lower  border  of  the  abscess  and  fetid  pus 
evacuated.  Staphylococci  and  putrefactive  bacteria 
were  found  in  the  pus.  Owing  to  the  previous  treat- 
ment of  the  patient  with  poultices,  the  bone  was  con- 
siderably denuded  of  periosteum.  Healing  took 
place  in  fourteen  days. 

943 


Osteomyelitis 


OSTEOMYELITIS  MAXILLA  INFERIORIS 

(Osteomyelitis  of  the  lower  jaw) 
Plate  LXXXII,  Fig.  104. 
OSTEOMYELITIS  SCAPULA  ACUTA 

(Acute  osteomyelitis  of  tlie  scapula) 
Plate  LXXXIII,  Fig.  105. 
OSTEOMYELITIS  HUMERI  CHRONICA 

(Chronic  osteomyelitis  of  the  Jnimerns) 
Plate  LXXXIV,  Fig.  106. 
OSTEOMYELITIS  TEBL^— NECROSIS  TOTALIS 

(Osteomyelitis  and  necrosis  of  the  tibia) 
Plate  LXXXV,  Fig.  107. 

The  term  osteomyelitis  is  applied  to  pyogenic 
affections  of  bone  in  general,  while  in  the  stricter 
sense  these  are  divided  into  purulent  periostitis, 
osteitis  and  osteomyelitis.  Since  all  three  parts  of 
the  bone  are  generally  the  seat  of  suppuration  and 
the  process  can  only  be  localized  clinically  to  the 
bones  as  a  whole,  and  as  the  majority  of  cases  begin 
with  infection  of  the  bone-marrow,  the  name  osteo- 
myelitis is  rational. 

Infection  of  the  bones  may  result  from  lesions  of 
the  soft  parts,  compound  fractures,  operations  (this 
was  common  after  amputations  in  the  pre-antiseptic 
days);  after  pyogenic  affections  of  the  neighboring 
parts  (subcutaneous  abscess,  whitlow,  otitis  media). 
In  the  latter  cases  the  periosteum  is  first  infected, 
the  cocci  then  invade  the  Haversian  canals  in  the 
cortex  and  infect  the  medullary  cavity.  As  in  all 
pyogenic  infections,  the  great  majority  of  cases  are 
caused  by  the  staphylococcus  pyogenes  aureus;  while 
the  staphylococcus  albus,  pneumococcus  and  strepto- 
cocci only  in  rare  cases  cause  infection  of  bone. 

244 


Apart  from  the  above-mentioned  modes  of  infec- 
tion this  may  take  place  through  the  blood;  the 
medulla  is  then  first  infected,  and  the  suppuration 
spreads  to  the  cortex  and  periosteum,  finally  appear- 
ing as  a  subcutaneous  abscess. 

In  all  pyogenic  affections  (furunculosis,  whitlow, 
quinsy,  otitis  media)  the  bone  marrow  is  infected  by 
staphylococci,  but  the  power  of  resistance  of  the 
body  is  generally  sufficient  to  withstand  their  action. 
The  cocci  remains  harmless  till  the  power  of  resistance 
of  the  body  is  weakened  by  some  exciting  cause,  such 
as  fracture,  overexertion,  exposure  to  cold,  etc.  Osteo- 
myelitis may  thus  occur  after  injury  to  a  bone,  even ' 
after  a  slight  contusion.  In  this  case  the  result- 
ing eflFusion  of  blood  favors  further  growth  of  the 
cocci  and  leads  to  infection.  It  follows  from  this 
that,  according  to  the  circumstances,  purulent  infec- 
tion of  the  bones  may  develop  sometimes  directly 
after  and  sometimes  a  long  time  after  purulent  inflam- 
mation in  other  organs  of  the  body;  also  that,  accord- 
ing to  the  number  and  virulence  of  the  bacteria,  it 
may  assume  an  acute  or  chronic  form,  with  corre- 
sponding violent  or  mild  s^Tnptoms.  Like  all  puru- 
lent inflammations,  the  process  begins  at  the  seat  of 
infection  with  hypersemia,  exudation,  suppuration, 
degeneration  and  regeneration;  these  processes  as- 
suming a  special  form  corresponding  to  the  structure 
of  the  bone.  Thrombo-phlebitis  may  occur  and  give 
rise  to  metastatic  infection  by  embolism  in  other 
parts  of  the  body  (bones,  endocardium,  meninges, 
etc.) 

As  the  great  majority  of  cases  arise  from  blood 
infection,  it  is  clear  that  the  bones  most  liable  to 
infection  are  those  which  are  most  richly  supplied 
with  blood-vessels,  especially  during  their  period  of 
growth  when  they  are  most  vascular.  The  diaphyses 
of  the  long  bones  are  thus  most  often  affected  at  their 
junction  with  the  epiphyses.  The  lower  ends  of  the 
femur  and  radius  and  tibia,  and  the  upper  ends  of 

245 


the  humerus  and  tibia  are  the  places  of  predilection. 
Osteomyelitis  is  rare  in  the  short  bones  and  in  the 
flat  bones.  It  is  also  rare  after  the  thirtieth  year. 
According  to  the  statistics  of  Garres,  in  one-fifth  of 
the  cases  several  bones  are  affected  simultaneously. 

The  symptoms  of  acute  purulent  osteomyelitis  are 
more  severe  than  in  any  other  pyogenic  affection. 
The  deeper  the  infection,  the  greater  is  the  virulence 
of  the  bacteria.  Bacteria  in  the  bone-marrow  are 
under  greater  pressure  than  in  any  other  tissue,  and 
this  increases  their  virulence.  In  young  individuals 
osteomyelitis  often  occurs  suddenly  after  an  injury, 
with  high  fever,  rigors,  pains  in  the  joints  and  severe 
constitutional  disturbance.  Pain  on  pressure  and 
movement,  and  loss  of  function  point  to  an  affection 
of  the  bones.  Serous  effusion  soon  takes  place  in  the 
nearest  joint.  Changes  first  appear  under  the  skin 
when  pus  forms  under  the  periosteum.  The  sub- 
periosteal abscess  appears  as  a  sharply  defined  fluc- 
tuating swelling  with  hard  borders,  and  the  skin  over 
it  is  tense  and  reddish  blue.  If  the  subperiosteal 
abscess  bursts,  it  gives  rise  to  intermuscular  and  sub- 
cutaneous infiltration,  with  redness  and  swelling  of 
the  skin,  and  oedema  of  the  soft  parts;  the  regional 
lymphatic  glands  are  swollen  and  painful. 

Although  operation  often  only  reveals  a  sub- 
periosteal abscess,  especially  in  children,  in  cases  of 
hematogenous  origin  (blood  infection)  the  cortex  and 
medulla  of  the  bone  are  also  affected.  Infection  of 
the  cortex  is  shown  by  the  presence  of  yellow  spots 
on  the  surface,  which  correspond  to  small  holes  dis- 
charging pus.  After  removal  of  the  cortex,  the 
infected  medulla  shows  reddish-brown  or  yellowish 
spots,  which  may  lead  to  the  formation  of  a  circum- 
scribed abscess,  or  to  diffuse  suppuration  in  the 
medullary  cavity.  If  the  condition  is  not  recognized 
early  and  the  spread  of  infection  arrested  by  opera- 
tion, separation  of  the  epiphyses  or  infection  of  the 
joint  may  occur,  or  general  infection  with  death  in 

246 


a  few  days.  In  extensive  disease  the  whole  bone  is 
whitish-yellow;  white  from  bloodlessness  due  to 
thrombo-phlebitis,  and  yellow  from  pus  formation. 
Numerous  pits  are  seen  from  which  pus  has  been 
discharged  under  the  periosteum. 

The  amount  of  necrosis  corresponds  to  the  degree 
and  extent  of  infection.  In  subperiosteal  necrosis 
the  infected  cortex  and  medulla  may  regenerate 
without  loss  of  substance,  especially  when  the  pus 
has  obtained  an  early  exit.  If  the  cortex  has  been 
for  some  time  the  seat  of  extensive  purulent  inflam- 
mation necrosis  must  result  with  the  formation  of  a 
sequestrum.  According  to  the  extent  of  the  inflam- 
mation this  necrosis  will  be  limited  to  one  part  of  the 
bone  or  extend  through  the  thickness  and  length  of 
the  bone  partially  or  completely.  In  disease  of  the 
cortex  the  sequestrum  is  generally  lamelliform, 
slightly  corroded  and  pitted;  in  disease  of  the 
medullary  cavity  the  sequestrum  is,  to  a  certain 
extent,  a  cast  of  the  cavity,  and  in  the  form  of  a 
trough. 

The  sequestrum  in  osteomyelitis  is  large  and  con- 
tinuous and  may  include  the  whole  length  and 
thickness  of  the  diaphysis  (Fig.  107),  thus  differing 
from  the  sequestra  in  tuberculous  bone  disease, 
which  are  generally  multiple,  small  and  much  cor- 
roded. Such  complete  necrosis  occurs  in  acute  cases 
which  have  been  operated  upon  too  late  and  in 
chronic  cases.  The  dead  bone  (sequestrum)  be- 
comes separated  from  the  healthy  bone  by  a  zone  of 
inflammatory'  demarcation,  more  or  less  rapidly 
according   to   its   size. 

In  extensive  necrosis  the  demarcation  process  may 
continue  for  months,  so  that  patients  who  escape 
death  from  general  infection  may  succumb  from 
exhaustion,  albuminuria  or  amyloid  degeneration  of 
the  kidneys.  Spontaneous  expulsion  of  the  dead 
bone  should  be  assisted  by  operation  (sequestrot- 
omy). 

247 


The  regenerative  or  osteoplastic  process  goes  hand 
in  hand  with  the  degenerative.  The  purulent  in- 
flammation not  only  causes  necrosis,  but  causes 
irritation  which  stimulates  the  periosteum  to  form 
new  bone  (osteoplastic  periostitis).  This  results  in 
thickening  of  the  cortex  at  the  seat  of  necrosis;  and 
in  cases  of  total  necrosis,  complete  repair  of  the 
destroyed  bone.  This  irregular  formation  of  new 
bone  is  sometimes  called  the  "sequestral  capsule." 
There  are  numerous  holes  (cloacas)  in  this  capsule 
where  the  periosteum  has  been  destroyed.  From 
these  holes  pus  is  discharged  from  the  zone  of  inflam- 
matory demarcation,  and  eventually  the  sequestrum, 
through  a  fistula  in  the  skin  (Fig.  107).  The  X-rays 
are  useful  in  showing  the  extent  of  necrosis,  and  also 
separation  of  the  epiphyses. 

The  whole  process  of  degeneration  and  regenera- 
tion take  much  longer  than  in  purulent  inflammation 
of  the  soft  parts,  and  the  acute  stage  is  followed  by  a 
chronic  stage  after  the  pus  has  been  evacuated  spon- 
taneously or  by  operation.  However,  an  acute 
relapse  may  occur  at  any  time  during  the  chronic 
stage,  especially  after  improper  treatment,  or  after 
an  injury. 

In  distinction  to  this  form  of  acute  osteomyelitis 
there  is  a  subacute  form  which  is  chronic  from  the 
beginning.  In  these  cases  there  is  often  a  history  of 
previous  acute  inflammation  of  the  bone,  and  the 
condition  is  really  one  of  recurrence  in  a  milder  form, 
often  at  the  age  of  puberty.  Recurrence  may  also 
occur  later  in  life,  hence  bones  which  have  been  pre- 
viously affected  with  osteomyelitis  must  be  regarded 
as  places  of  less  resistance  and  must  be  protected 
from  the  action  of  trauma  and  over-exertion. 

The  clinical  symptoms  in  these  cases  often  resemble 
rheumatic  pains,  but  the  pain  is  localized  to  one  bone, 
or  sometimes  a  definite  part  of  a  bone.  There  is 
often  a  history  of  pyogenic  disease  in  youth,  and 
scars  and  fistulas  may  be  found  in  the  bone  con- 

248 


cerned  or  in  other  bones.  The  affected  bone  is  often 
very  tender  to  pressure  at  certain  points.  In  the 
course  of  time  the  bone  becomes  thickened,  and  the 
diaphysis  lengthened.  The  growth  in  thickness  may 
be  enormous  at  the  seat  of  disease,  the  thickening 
being  both  periosteal  and  cortical. 

The  changes  in  the  bone  in  chronic  osteomyelitis 
are  as  follows:  Sometimes  there  is  a  small  sequestrum 
in  the  interior  of  the  bone,  shown  as  a  clear  spot  sur- 
rounded by  bony  proliferation  in  an  X-ray  picture; 
sometimes  a  circumscribed  abscess  in  the  medullary 
cavity,  shown  by  the  X-rays  as  a  round  space  sur- 
rounded by  bone.  If  bony  proliferation  is  absent 
the  X-ray  pictures  resemble  tumors  or  cysts  in  the 
bone.  The  diagnosis  of  chronic  osteomyelitis  is, 
therefore,  sometimes  difficult  when  there  is  no  his- 
tor}-  or  evidence  of  former  osteomyelitis.  Pain  on 
pressure  suggests  the  infective  nature  of  the  disease. 
In  doubtful  cases  search  may  be  made  for  staphylo- 
lysin,  according  to  the  method  of  Bruch,  Michaelis 
and  Schultze. 

If  large  portions  of  the  cortex  and  medulla  are 
affected  by  chronic  osteomyelitis  large  sequestra  are 
formed,  which  seek  a  way  to  the  surface  in  spite  of 
the  considerable  formation  of  new  bone.  In  these 
cases  we  find  numerous  cloacas  in  the  bony  capsule, 
subcutaneous  abscess  and  fistulas  (Fig.  106);  while 
the  whole  bone  is  thickened,  and  the  X-rays  show 
changes  in  the  periosteum,  cortex  and  medulla. 

A  third  form  of  chronic  osteomyelitis  is  limited  to 
the  periosteum,  under  which  a  hyaline  sero-mucoid 
fluid  develops,  forming  a  sharply  defined,  fluctuating 
swelling  with  hard  borders.  This  has  been  called 
albuminous  periostitis  but  is  a  form  of  osteomyelitis. 
Staphylococci  are  present  in  the  fluid. 

All  these  chronic  forms  are  due  to  infection  by  less 
virulent  staphylococci.  However,  every  chronic  os- 
teomyelitis may  become  acute,  especially  when  the 
bones   are   exposed   to   the    effects    of    overexertion, 

249 


injury,  or  massage  (performed  on  account  of  wrong 
diagnosis).  Chronic  fistulas  in  osteomyelitis  may 
give  rise  to  carcinoma  (cf.  Plate  XIV).  In  the 
long  bones  both  acute  and  chronic  osteomyelitis  may 
cause  disturbance  in  growth,  pseudarthrosis  and  con- 
tractures. Although  the  great  majority  of  cases  of 
acute  and  chronic  osteomyelitis  affect  the  long  bones, 
both  forms  may  occur  in  the  short  and  flat  bones;  in 
the  skull,  after  compound  fractures,  incised  and 
punctured  wounds;  in  the  scapula,  pelvic  bones  and 
vertebrae;  in  the  bones  of  the  face  (after  tooth 
extraction).  In  Frbhnefs  statistics,  four  hundred 
and  seventy  cases  of  osteomyelitis  affected  the  long 
bones  and  thirty-four  the  short  and  flat  bones.  As 
the  cortex  is  thin  in  these  bones,  there  is  greater 
destruction.  Osteomyelitis  of  the  cranial  bones  may 
spread  through  the  diploe  to  half  the  skull,  form  large 
sequestra  of  the  inner  table,  and  epidural  abscess. 
In  the  scapula  the  whole  bone  may  be  destroyed  by 
multiple  abscesses  and  sequestra,  necessitating  com- 
plete removal  of  the  bone.  In  osteomyelitis  of  a 
facial  bone,  infection  may  spread  to  all  the  bones  of 
the  face,  causing  extensive  destruction  and  conse- 
quent deformity.  Osteomyelitis  of  the  cranial  and 
facial  bones  may  give  rise  to  meningitis. 

In  streptococcal  osteomyelitis  the  pus  is  thinner 
and  very  abundant,  and  the  disease  is  more  severe 
like  all  streptococcal  infections.  In  these  cases  the 
skin  usually  shows  erysipelatous  reddening. 

Osteomyelitis  after  infection  by  typhoid  bacilli  or 
pneumococci  can  only  be  distinguished  from  the 
other  forms  by  the  history  and  by  bacteriological 
examination. 

Differential  Diagnosis.  Acute  osteomyelitis 
may  be  mistaken  for  deep  abscess,  but  this  is  made 
clear  by  incision.  The  redness  of  the  skin  in  osteo- 
myelitis resembling  erysipelas  is  limited  to  the 
affected  part  and  gradually  diminishes.     Acute  osteo- 

250 


myelitis  of  the  diaphyses  is  characterized  by  the 
severity  of  the  symptoms,  the  marked  swelUiag  and 
the  loss  of  power  in  the  limb. 

Chronic  forms  are  most  often  mistaken  for  tuber- 
culous bone  disease,  but  the  latter  generally  affects 
the  epiphyses,  while  osteomyelitis  attacks  the  dia- 
physes. Osteomyelitic  fistula  has  hard  borders  and 
bright  red  granulations,  and  passes  directly  to  the 
bone,  while  tuberculous  fistula  has  yellow,  slimy 
granulations,  irregular  borders  and  an  irregular 
course  through  the  deep  parts  (Figs.  125  and  130). 
In  osteomyelitis  the  pus  is  reddish  brown,  in  tuber- 
culosis it  is  thin  and  greenish  yellow.  In  doubtful 
cases  an  incision  will  decide  the  diagnosis;  in  osteo- 
myelitis the  periosteum  and  cortex  will  be  found 
thickened  and  the  sequestrum  large  and  continuous; 
in  tubercular  bone  disease  there  are  multiple,  small 
corroded  sequestra. 

Chronic  osteomyelitis  causing  much  swelling  of  the 
bone  may  be  mistaken  for  syphilitic  bone  disease, 
especially  in  the  tibia.  In  syphilitic  bone  disease  the 
X-rays  show  a  diffuse  thickening  of  all  layers  of  the 
bone,  and  a  uniform  dark  shadow  with  irregular 
borders,  corresponding  to  the  periosteum;  while,  in 
osteomyelitis,  dark  shadows  together  with  clear 
spaces  are  shown,  corresponding  to  sequestra  and 
abscesses  respectively.  If  fistulas  form  in  syphilitic 
bone  disease  they  present  the  characteristic  sharp 
borders  and  prolific  granulation  tissue  round  them 
(Fig.  122). 

Osteitis  deformans  (Paget's  disease)  is  characterized 
by  affecting  the  whole  extent  of  both  tibias,  and  by 
the  early  appearance  of  marked  curvature. 

Osteomyelitic  abscesses  in  the  diaphysis,  when 
they  extend  to  the  epiphyses  may  be  mistaken  for 
tuberculosis,  but  the  pronounced  new  bone-formation 
is  absent  in  the  latter.  Sarcoma  and  bone-cysts  may 
also  in  some  cases  be  difficult  to  distinguish  from 
chronic  osteomyelitic  abscess,  even  by  the  X-rays. 

251 


In  doubtful  cases  an  exploratory  incision  may  be 
made,  or  staphylolysin  looked  for. 

In  the  majority  of  cases,  however,  the  diagnosis  of 
osteomyelitis  is  established  by  the  history  and  the 
typical  appearance,  situation  and  course  of  the 
disease. 

The  earlier  diagnosis  is  made  and  treatment  com- 
menced, the  better  the  prognosis. 

Treatment.  In  the  most  acute  cases  with  puru- 
lent joint-etfusion  and  signs  of  general  infection  (dry 
tongue,  delirium,  presence  of  bacteria  in  the  blood) 
amputation  is  sometimes  the  only  means  of  saving 
life. 

In  acute  osteomyelitis  incision  must  be  made  as 
soon  as  possible,  before  the  abscess  has  broken  into 
the  subcutaneous  tissue.  After  opening  the  abscess 
the  bone  must  be  examined;  if  it  is  unaltered  it  can 
be  left  alone.  If  the  temperature  does  not  fall  after 
opening  the  abscess  and  the  condition  becomes  worse, 
with  rigors,  etc.,  the  bone  must  be  laid  open  as  far 
as  the  medullary  cavity.  This  should  be  performed 
freely  with  a  gouge ;  it  is  useless  simply  to  bore  holes 
as  they  do  not  give  sufficient  outlet  for  pus,  nor  for 
subsequent  necrosed  pieces  of  bone.  On  the  other 
hand,  in  cases  with  severe  constitutional  symptoms, 
especially  in  children,  the  whole  extent  of  bone 
should  not  be  gouged  at  one  sitting,  owing  to  the 
severe  shock,  and  the  possibility  of  general  infection; 
the  gouging  should  be  performed  at  several  sittings. 
After  gouging,  the  infiltrated  bone-marrow  must  be 
scraped  with  the  sharp  spoon  and  the  cavity  drained 
with  iodoform  gauze.  The  wound  must  be  kept 
open  by  a  drainage  tube  to  allow  pus  and  sequestra 
to  escape. 

The  after-treatment  is  sometimes  hindered  by  nar- 
rowing of  the  opening  in  the  bone  from  the  formation 
of  callus;  if  there  is  no  suspicion  of  necrosis,  this 
callus  must  be  removed  with  the  knife,  to  establish 

252 


sufficient  communication  with  the  medullary  cavity. 
Complete  immobilization  is  necessary  in  the  extremi- 
ties, to  avoid  spread  of  inflammation  and  the  possi- 
bility of  fracture. 

Serous  effusion  into  a  joint  must  be  punctured 
when  extensive.  Purulent  effusion  requires  incision, 
and  sometimes  resection  of  the  joint.  If  there  is 
purulent  arthritis  with  high  fever  and  rigors,  resection 
must  not  be  delayed,  or  general  infection  may  follow. 

In  chronic  osteomyelitis  it  is  best  to  wait  till  the 
sequestrum  is  complete  and  new  bone  has  begun  to 
form  round  it  (X-ray  examination)  before  performing 
sequestrotomy.  If  there  are  subcutaneous  abscesses 
these  must  be  opened.  As  small  sequestra  and  ab- 
scesses often  cause  considerable  pain,  in  some  cases 
the  bone  must  be  gouged  when  the  X-ray  examination 
shows  no  changes.  The  operation  is  troublesome,  as 
the  small  sequestrum  or  abscess  is  often  situated  in 
the  middle  of  hardened  sclerotic  bone.  The  fistulas 
in  chronic  osteomyelitis  must  be  freely  opened  up 
and  the  callus  removed.  The  cavity  in  the  bone  left 
after  gouging  must  be  left  open  and  drained  till  heal- 
ing takes  place  from  the  bottom.  Immediate  plug- 
ging of  the  bone  cavity  with  iodoform  is  only  of  use 
in  a  few  cases  of  circumscribed  chronic  osteomyelitis, 
as  in  extensive  cases  the  plugs  are  often  expelled 
through  a  fistula;  but  when  the  cavity  is  filled  with 
fresh  granulations,  all  cases  of  osteomyelitis  can 
quickly  be  made  to  heal  with  plugging.  The  cavity 
is  then  scraped,  disinfected  with  peroxide  lotion, 
dried  with  Hollander's  hot  air  apparatus,  and  filled 
with  a  mixture  of  iodoform,  glycerin  and  spermaceti. 
^Mienever  possible,  the  periosteum  should  be  united 
over  the  plug  and  a  covering  of  skin  made  over  the 
cavity.     Strict  asepsis  is  necessary. 

Frequent  recurrences  in  chronic  osteomyelitis,  with 
emaciation,  albuminuria,  etc.,  necessitate  amputa- 
tion. Contractures  must  be  treated  by  extension  on  a 
splint,  or  when  they  cannot  be  extended,  by  resection. 

253 


Large  defects  in  the  skin  can  be  covered  by  peduncu- 
lated flaps. 

In  the  flat  bones  subperiosteal  removal  of  the  whole 
bone  is  often  necessary  {e.g.  scapula).  This  may  be 
followed  by  complete  regeneration  and  restoration  of 
function.  In  osteomyelitis  of  the  cranium  sequestra 
and  epidural  abscesses  must  be  evacuated  through  a 
large  trephine  hole,  which  can  afterwards  be  repaired 
by  bone  grafting. 

Treatment  of  acute  osteomyelitis  by  passive  hyper- 
femia  is  to  be  condemned,  as  it  obscures  the  signs  and 
symptoms.  It  may  also  lead  to  diffuse  suppuration 
by  thrombo-phlebitis,  rendering  amputation  neces- 
sary; but  its  chief  danger  is  general  infection. 


254 


Bockenheimer,  Atlas. 


Tab.  LXXXII. 


Pig.  104.     Osteonivflitis  maxillae  inferioris. 


Rfbman  Coni|)aiiy,  New-Vork. 


OSTEOMYELITIS  MAXILLAE  INFERIORIS 

(Ostcomi/clitis  of  the  Loirer  Jaio) 
Plate  LXXXII,  Fig.  104. 

This  figure  shows  chronic  osteomveHtis  in  a  eirl  of 
nineteen,  which  occurred  in  connection  with  tooth 
extraction.  Osteomyelitis  of  the  lower  jaw  often 
occurs  after  tooth  extraction,  when  there  is  much 
inflammation  of  the  gum  and  periosteum,  or  when 
the  alveolus  is  extensively  injured.  It  may  also  fol- 
low injuries  to  the  jaw.  Osteomyelitis  of  the  lower 
jaw%  due  to  blood  infection,  is  generally  combined 
with  disease  of  other  bones,  and  occurs  especially  in 
children.  Acute  osteomyelitis  of  the  lower  jaw  com- 
mences with  high  fever,  rigors,  oedema  of  the  face 
and  mucous  membrane  of  the  mouth,  difficulty  in 
breathing  and  swallowing,  headache  and  delirium. 
It  is  often  fatal  from  meningitis  or  general  infection. 
In  some  cases  the  whole  of  the  lower  jaw  may  become 
necrosed. 

In  the  chronic  form  (Fig.  104)  a  painless  circum- 
scribed or  diffuse  painless  swelling  slowly  develops  in 
the  lower  jaw.  The  skin  gradually  becomes  tense, 
red  and  cedematous;  one  or  more  fistulas  develop, 
and  later  on  necrosis  takes  place.  In  extensive  cases 
the  teeth  become  loosened  and  trismus  may  occur. 
In  the  stage  of  painless  swelling  the  case  may  resem- 
ble cystic  adenoma.  In  actinomycosis  the  swelling 
is  situated  in  the  floor  of  the  mouth  and  in  the  mus- 
cles, and  only  extends  to  the  bones  later  on. 

Osteomyelitis  of  the  lower  jaw  should  be  treated 
by  early  incision  down  to  the  bone,  at  the  lower 
border  of  the  jaw.  Healing  without  necrosis  occurs 
more  often  than  in  the  long  bones.  If  necrosis 
occurs  it  is  best  to  wait,  in  chronic  cases,  till  sufficient 

255 


new  bone  is  formed,  so  as  to  avoid  fracture  of  the  jaw 
during  removal  of  the  sequestrum. 

Sequestra  are  best  removed  by  external  incisions. 
The  cavity  should  be  plugged  with  iodoform  gauze 
for  a  long  time.  In  extensive  necrosis,  bone  grafting 
may  be  tried,  or  the  patient  may  wear  a  prothesis. 

In  Fig.  104  the  fistula  was  opened  up;  after  which 
the  discharge  diminished,  but  the  swelling  of  the 
bone  remained  and  the  fistula  did  not  heal,  indicating 
necrosis.  The  X-rays  showed  diffuse  swelling  of 
the  jaw. 

A  condition  affecting  the  bones,  observed  by 
Billroth  in  workers  in  mother-of-pearl,  which  resem- 
bles osteomyelitis,  and  chiefly  affects  the  lower  jaw, 
undergoes  spontaneous  resolution;  so  long  as  the 
patients  are  not  exposed  to  fresh  injury  through  their 
work. 

Phosphorous  necrosis  of  the  lower  jaw,  which  occurs 
in  workers  in  yellow  phosphorus,  is  probably  due  to 
infection  of  the  bone.  The  phosphorous  vapor  causes 
ulceration  of  the  gums,  through  which  the  periosteum 
and  bone  are  infected.  This  condition  gives  rise  to 
great  swelling  of  the  whole  of  the  lower  jaw.  The 
teeth  become  loose  and  fall  out.  The  gums  become 
ulcerated  and  fetid,  so  that  many  patients  succumb 
to  septic  pneumonia  or  to  general  septic  infection. 
The  bone  becomes  both  sclerosed  and  brittle.  After 
some  years  total  necrosis  occurs  with  a  row  of  fistulas 
along  the  lower  border  of  the  jaw. 

As  there  is  generally  total  necrosis  in  these  cases, 
partial  resection  is  useless,  and  subperiosteal  resec- 
tion of  one  or  both  sides  of  the  jaw  should  be  per- 
formed. After  this  regeneration  of  the  jaw  takes 
place  if  the  periosteum  has  been  preserved,  and 
relapses  are  avoided. 

Phosphorous  necrosis  (which  is  fatal  in  fifty  per 
cent,  of  the  cases)  has  been  prevented  by  the  prohi- 
bition of  the  use  of  the  dangerous  yellow  phosphorus 
in  the  manufacture  of  matches. 

256 


Bockenheimer,  Atlas. 


Tab.  LXXXIII. 


Fig.  105.    Osteomyelitis  scapulae  acuta. 


Pcbman  Company,  New- York. 


OSTEOMYELITIS  SCAPULA  ACUTA 

(Acute  Osteomyelitis  of  the  Scapula) 
Plate  LXXXIII,  Fig.  105. 

This  is  a  case  of  acute  osteomyelitis  of  the  scapula 
following  an  injury.  A  few  days  after  the  injury  a 
swelling  appeared  over  the  whole  scapular  region  as 
far  as  the  supra-clavicular  fossa,  accompanied  by 
fever  and  rigors.  The  skin  became  red  and  mottled, 
and  a  large  fluctuating  subcutaneous  abscess  devel- 
oped. The  function  of  the  shoulder-joint  was  abol- 
ished. An  incision  was  made  and  pus  evacuated; 
the  bone  at  the  seat  of  injury  was  infiltrated  with  pus. 
Healing  took  place  without  any  necrosis. 

In  osteomyelitis  of  the  scapula,  especially  when  due 
to  blood  infection,  an  abscess  usually  forms  at  the 
anterior  border  of  the  scapula,  as  the  osteomyelitic 
focus  in  this  mode  of  infection  is  situated  in  the 
body  of  the  bone.  The  pus  is  at  first  limited  by  the 
subscapularis  muscle;  on  the  other  hand,  the  pres- 
sure of  the  muscle  causes  rapid  extension  of  suppu- 
ration in  the  medulla  of  the  bone.  The  abscess  may 
thus  not  be  recognized  till  it  breaks  through  into  the 
axilla.  An  early  symptom  of  osteomyelitis  of  the 
scapula  is  painful  effusion  into  the  shoulder  joint;  on 
this  account  it  may  be  mistaken  for  an  affection  of 
that  joint,  the  true  seat  of  disease  only  being  revealed 
after  incision.  In  doubtful  cases  the  anterior  surface 
of  the  scapula  should  be  exposed  by  an  incision  in 
the  axilla.  In  most  cases  of  osteomyelitis  of  the 
scapula,  the  wound  does  not  heal  after  incision  of  the 
abscess;  the  occurrence  of  multiple  abscesses  and 
necrosis  is  unavoidable,  owing  to  the  extension  of 
suppuration  through  the  medulla  of  the  bone.     For 

257 


this  reason  the  disease  may  last  for  years.  In  these 
cases,  and  also  in  acute  cases  where  incision  shows 
extensive  destruction  of  the  bone,  subperiosteal  total 
extirpation  of  the  scapula  is  indicated,  taking  care  to 
preserve  the  muscular  attachments  and  the  important 
nerves.  This  is  especially  indicated  in  acute  osteo- 
myelitis of  the  flat  bones,  which  often  gives  rise  to 
early  general  infection.  After  total  extirpation  of 
the  scapula  relapses  are  avoided,  and  complete  regen- 
eration of  bone  with  normal  function  is  possible 
{Bockenheimer) . 


258 


Bockenheimcr  Atlas. 


Tab.  LXXXIV. 


I'ig.  100.     Ostcoiiivelili^  liimic 


n  ciiroiiica. 


OSTEOMYELITIS  HUMERI  CHRONICA 

(Chronic  onteomi/elitis  of  the  Humerus) 
Plate  LXXXIV,  Fig.  106. 

Fig.  106  shows  a  painful  club-shaped  swelling  of 
the  left  humerus,  which  gradually  developed  at  the 
age  of  puberty,  in  a  patient  who  had  frequently 
suffered  from  tonsilitis  in  childhood.  The  patient 
attributed  it  to  over-exertion  at  his  work  as  a  black- 
smith. A  year  after  the  onset,  a  fistula  formed  at 
the  posterior  and  external  side  of  the  arm,  with  hard 
borders  and  red  granulations  at  its  orifice.  A  probe 
passed  down  the  fistula  discovered  rough  bone, 
denuded  of  periosteum.  Subcutaneous  abscesses 
formed  at  the  front  of  the  arm,  where  the  skin  was 
thin  and  reddened.  Examination  by  the  X-rays 
showed  a  sequestrum,  along  with  new  bone  forma- 
tion. Chronic  osteomyelitis  of  the  diaphysis  of  the 
humerus  was  diagnosed.  An  incision  was  made 
down  to  the  bone  in  the  lower  third  of  the  outer  side 
of  the  arm,  avoiding  the  radial  nerve.  The  perios- 
teum was  destroyed  at  one  place  and  a  cloaca  was 
found  leading  to  a  sequestrum.  The  sequestrum  was 
removed  by  carefully  gouging  the  bone;  the  cavity 
was  scraped  and  plugged,  and  the  fistulous  track 
with  its  hardened  walls  excised.  The  subcutaneous 
abscesses  were  opened  and  scraped.  The  arm  was 
immobilized  for  a  long  time.  Healing  took  place 
after  some  months,  and  the  patient  was  told  to 
choose  a  lighter  occupation  in  order  to  avoid  recur- 
rence of  the  disease. 


359 


OSTEOMYELITIS  TIBLE— NECROSIS  TOTALIS 

(Acute  Osteomi/elitiii  and  Xecrosis  oj  the  Tibia) 
Plate  LXXXV,  Fig.  107. 

In  this  case  acute  osteomyelitis  of  the  tibia  in  a 
child,  aged  nine  years,  commenced  with  severe  pain 
in  the  leg  and  knee  joint,  accompanied  by  high  fever 
and  rigors.  There  was  no  history  of  a  previous 
attack.  A  few  days  before  the  onset  the  child  re- 
ceived a  blow  on  the  tibia.  In  spite  of  the  severe 
clinical  symptoms  and  the  marked  swelling  of  the 
knee  joint,  operative  treatment  had  been  neglected, 
and,  only  when  a  subcutaneous  abscess  developed, 
was  an  incision  made.  Although  the  acute  symp- 
toms gradually  subsided  after  this,  the  swelling  of  the 
leg  remained,  and  the  wound  discharged  fetid  pus. 
In  a  few  months  almost  the  whole  shaft  of  the  tibia 
became  necrosed.  Fig.  107  shows  the  yellow  ne- 
crosed bone,  with  the  open  medullary  cavity  contain- 
ing slimy  granulations.  Between  the  necrosed  bone 
and  the  healthy  bone  are  granulation  tissue  and  pus. 
As  the  leg  had  not  been  properly  fixed,  a  fracture 
occurred  at  the  lower  part  of  the  tibia.  The  condi- 
tion of  the  child  on  admission  to  hospital  was  very 
bad,  owing  to  the  prolonged  suppuration.  Examina- 
tion by  the  X-rays  showed  that  the  sequestrum 
extended  further  down,  and  that  a  thick,  bony  cap- 
sule had  already  formed  behind  and  at  the  sides. 

Under  an  ansesthetic,  the  wound  was  extended 
downwards,  the  necrosed  bone  removed,  the  cavity 
scraped  and  plugged,  and  the  leg  put  up  on  a  splint 
with  extension,  to  correct  the  position  of  flexion. 
The  equinus  position  of  the  foot,  due  to  insufficient 
fixation,  was  gradually  corrected. 

Such  extensive  necrosis  could  have  been  avoided 
by  early  gouging  of  the  bone  and  proper  after- 
treatment. 

260 


Bockenheimer,  Atlas. 


Tab.  l.XXXV. 


Fig.  107.     Osteonnclitis  tibiae   -   Necrosis  totalis. 


Rcbman  Company,  New- York. 


Bockenheinier,  Atlas. 


Tab.  LXXXVI. 


Fig.  108. 


Infectio  eeneralisata. 


Rebmm  Company,  New-York. 


INFECTIO  GENERALISATA   {General  Infection) 
Plate  LXXXVI,  Fig.  108. 

In  the  description  of  the  various  local  pyogenic 
infections,  mention  has  already  been  made  of  gen- 
eral infection.  In  every  pyogenic  and  putrefactive 
infection  there  is  a  certain  degree  of  general  infection, 
but  this  is  not  generally  sufficient  to  be  recognized 
clinically  or  bacteriologically.  In  apparently  benign 
pyogenic  affections,  such  as  furuncle,  bacteria  may 
be  found  in  the  blood.  This  explains  the  occasional 
occurrence  of  metastatic  osteomyelitis  in  connection 
with  such  affections;  and  also  the  fact  that  the  im- 
pairment in  general  health  is  often  out  of  proportion 
to  the  local  inflammation. 

General  infection  assumes  different  clinical  forms, 
but  it  is  impossible  to  make  a  classification  of  these 
which  is  free  from  objection.  Moreover,  such  a 
division  is  of  little  practical  value,  as  the  same  meas- 
ures must  be  employed  against  different  forms  of 
general  infection.  From  the  clinical  point  of  view, 
it  is,  therefore,  best  to  speak  only  of  general  infec- 
tion, and  abandon  the  old,  and  often  inappropriate, 
terms  sepsis,  septicaemia  and  pyaemia.  In  any  case 
the  term  sepsis  should  be  confined  only  to  that  form 
of  general  infection  which  is  caused  by  the  putre- 
factive bacteria;  but  this  form  is  rare,  and  it  is  gen- 
erally a  question  of  mixed  infection  with  putrefactive 
bacteria  and  streptococci. 

Again,  the  distinction  into  metastatic  and  non- 
metastatic  general  infection,  proposed  by  Lexer,  is 
practically  without  value  and  does  not  hold  good 
for  all  cases.  In  many  cases  non-metastatic  cannot 
be  distinguished  from  metastatic  general  infection, 

261 


especially  as  both  often  co-exist,  or  one  may  merge 
into  the  other.  Lastly,  when  only  small  metastases 
are  present  in  the  internal  organs,  and  they  remain 
unrecognized,  such  a  metastatic  form  may  be  wrongly 
regarded  as  non-metastatic. 

Bacteriological  research  has  shown  that  general  in- 
fection is  not  due  to  one  specific  cause;  staphylo- 
cocci, streptococci,  pneumococci,  typhoid  bacilli,  bac- 
terium coli  commune  give  rise  to  p?jogenic  general 
infection,  while  putrefactive  bacteria  (proteus  vul- 
garis, etc.)  cause  putrefactive  general  infection.  These 
two  forms  are  often  combined,  and  clinically  indis- 
tinguishable, so  that  the  designation  general  infection 
is  sufficient  for  practical  purposes.  On  the  other 
hand,  the  nature  of  individual  cases  should  be  made 
clear  by  bacteriological  investigation. 

It  has  been  shown  that  in  general  infection  caused 
by  staphylococci  there  are  usually  metastasic  forma- 
tions (ninety-five  per  cent,  according  to  Lehnartz). 
Local  infection  with  staphylococci  is  generally  cir- 
cumscribed, while  streptococcal  infection  is  more 
diffuse.  This  may  depend  on  the  fact  that  the  staphylo- 
cocci are  accumulated  in  large  masses,  but  it  has  not 
been  proved. 

In  streptococcal  general  infection,  on  the  other 
hand,  there  are  hardly  ever  any  metastatic  forma- 
tions. As  cases  without  metastases  are  clinically  the 
most  severe,  and  almost  always  fatal,  a  division  into 
metastatic  and  non-metastatic  general  infection  is 
identical  with  less-severe  and  more-severe  infection. 
However,  just  as  infection  with  very  virulent  staphylo- 
cocci may  be  fatal  without  metastatic  formation,  so 
may  infection  with  less  virulent  streptococci  cause 
metastatic  formation  and  end  in  recovery.  In  prac- 
tice, we  know  that  streptococcal  local  infection  is 
more  severe  than  staphylococcal,  and  this  usually 
holds  with  general  infection. 

It  is  impossible  to  introduce  the  ideas  of  bacteri- 
semia  and  toxinaemia  into  clinical  nomenclature,  for 

262 


the  characterization  of  general  infection.  Although 
general  infection  may  exist  without  the  presence  of 
bacteria  in  the  blood  being  capable  of  demonstration 
by  the  present  methods  of  bacteriological  research, 
bacteria  are  no  doubt  present  in  the  blood  in  every 
case  of  general  infection,  but  are  quickly  destroyed 
by  the  bactericidal  substances.  On  the  other  hand, 
bacteria  may  be  found  in  the  blood  in  cases  of  gen- 
eral infection  in  which  toxinsemia  is  not  recognizable. 
If  toxins  are  always  present  in  the  blood,  they  are 
not  easy  to  find,  especially  as  they  have  a  tendency 
to  form  combinations  with  the  organs.  In  general 
infection  there  is  always  bacterisemia  and  toxin- 
semia,  but  in  practice  we  only  speak  of  general  infec- 
tion which  is  most  often  acute,  rarely  chronic. 

Acute  general  infection  may  be  primary  or  sec- 
ondary; mild  or  severe.  The  severity  of  general 
infection  depends  on  the  number  and  virulence  of 
the  bacteria,  and  on  the  power  of  resistance  of  the 
body.  The  severest  forms  of  general  infection 
appear  so  rapidly  after  the  local  infection  that  the 
latter  remains  in  the  background;  these  forms  are 
often  fatal  before  the  typical  inflammatory  processes 
have  developed  at  the  seat  of  infection.  Such  cases 
include  those  which  often  occur  in  doctors  from 
infection  during  operations  or  post-mortem  examina- 
tions (streptococcal  infection) ;  also  from  infection 
by  putrefactive  bacteria;  or  by  mixed  infection  by  a 
symbiosis  of  streptococci  and  putrefactive  bacteria. 
To  this  class  belong  cases  formerly  called  crypto- 
genetic  pyaemia,  which  are  better  considered  as 
latent  general  infection  arising  from  unrecognizable 
foci  of  infection.  Virulent  bacteria  must  often  invade 
the  intact  mucous  membrane  and  give  rise  to  general 
infection. 

In  the  great  majority  of  cases,  however,  general 
infection  is  of  gradual  onset,  arising  from  a  local 
infection;  but  it  is  often  in  an  advanced  condition 
before   it   is   recognized.     It   may   occur   by   direct 

263 


extension  of  suppuration,  or  may  arise  without 
further  extension  of  the  local  disease. 

The  more  rapidly  virulent  bacteria  enter  the  blood 
from  the  local  seat  of  infection,  the  more  severely  is 
the  organism  affected.  This  is  shown  in  the  tem- 
perature chart. 

In  the  most  severe  forms  the  temperature  rises 
rapidly  and  remains  at  40°  or  42°  C.  (104°-107°  F.) ; 
such  cases  generally  cause  death  in  a  few  days  with- 
out metastatic  formations.  In  less  severe  forms  the 
temperature  does  not  remain  high,  but  is  intermittent. 
This  may  be  due  to  the  intermittent  entry  of  the 
bacteria  and  their  toxins  into  the  blood  from  the 
seat  of  infection,  or  to  smaller  quantities  of  them. 
When  the  organism  conquers  the  bacteria  and  their 
toxins  by  the  formation  of  antitoxin,  the  temperature 
falls;  when  the  bacteria  gain  the  upper  hand  the 
temperature  rises. 

The  longer  the  process  continues,  the  more  fre- 
quent are  the  rigors,  with  intermissions  of  tempera- 
ture. When  these  variations  in  temperature  follow 
each  other  rapidly  (as  occurs  in  the  severest  cases) 
the  temperature  becomes  continuous,  the  rigors  cease 
and  there  are  no  metastases.  If  the  organism  gains 
the  upper  hand,  the  infection  expends  its  energy  in 
the  formation  of  local  metastatic  formations  in 
various  places.  This,  in  a  way,  may  be  regarded  as 
a  victory  of  the  organism  over  the  bacteria. 

In  the  milder  forms  of  general  infection  we  there- 
fore find  metastatic  formations  in  those  parts  of  the 
body  which  are  specially  constituted  to  absorb  bac- 
teria and  render  them  harmless  (peritoneum,  pleura, 
endocardium  joint  cavities).  Metastatic  formation 
is  to  be  regarded  as  a  curative  process,  as  the  bacteria 
are  to  a  great  extent  destroyed.  These  metastases 
caused  by  bacteria  in  the  blood  must  be  distinguished 
from  metastases  propagated  from  purulent  thrombo- 
phlebitis, or  emboli  containing  bacteria.  In  all  these 
cases  the  blood-stream  plays  the  principal  part  in 

264 


general  infection,  the  role  of  the  lymphatics  being 
subordinate. 

As  in  local  infection,  general  infection  is  predis- 
posed to  by  debilitation  of  the  organism  by  exhaus- 
tion, hunger,  and  exposure  to  cold,  and  by  diseases 
such  as  diabetes  and  tuberculosis,  etc.  Along  with 
general  predisposition,  there  is  a  local  predisposition 
depending  on  the  nature  and  seat  of  the  lesion. 
Foreign  bodies  often  lead  to  general  infection,  also 
machine-injuries,  compound  fractures,  bites,  and 
wounds  of  the  mouth  and  rectum. 

The  deeper  the  infection  and  the  greater  the  pres- 
sure on  the  bacteria,  the  greater  is  their  virulence, 
and  therefore  the  more  frequent  is  general  infection. 
This  accounts  for  the  frequency  of  general  infection 
in  deep  suppurations,  such  as  those  under  the  cervical 
fascia,  and  in  the  bones  and  joints.  It  is  well  known 
that  the  internal  surface  of  the  uterus  durinjr  the 
puerperium  is  especially  liable  to  infection,  which 
may  become  general,  and  that  the  retention  of  pus 
and  blood  effusions  are  dangerous.  Lastly,  the  treat- 
ment of  infected  wounds  with  strong  caustics,  such  as 
carbolic  acid,  may  give  rise  to  general  infection. 

As  regards  the  clinical  symptoms  of  general  infec- 
tion, various  clinical  pictures  may  be  produced 
according  to  the  kind  of  infection,  but  the  morbid 
condition  is  uniform  as  regards  its  most  essential 
points.  Bacteriological  examination  must  decide 
which  bacteria  have  caused  the  infection,  whether 
one  or  more  different  kinds  are  present,  and  whether 
they  are  present  in  the  blood  (bacterisemia).  As 
regards  metastases,  we  can  only  speak  of  metastatic 
general  infections  when  metastases  are  found  during 
life;  while  cases  in  which  no  metastases  are  found 
cannot  be  called  non-metastatic  till  the  absence  of 
metastases  has  been  established  by  post-mortem 
examination.  Small  metastatic  foci  are  often  found 
post-mortem  (especially  in  the  kidneys),  which  were 
not  recognizable  during  life. 

265 


The  symptoms  of  general  infection  differ  according 
as  the  onset  is  sudden  and  acute,  or  gradual  and 
chronic.  In  the  most  acute  forms  the  symptoms 
appear  suddenly,  while  in  the  other  forms  there  is  a 
latent  stage  with  disturbances  in  the  general  condi- 
tion (insomnia,  loss  of  appetite,  headache,  pain  at 
the  seat  of  infection)  which  are  premonitory  of  gen- 
eral infection.  A  frequent  small  pulse  points  to  the 
onset  of  general  infection,  before  the  rise  of  tempera- 
ture. The  temperature  then  rises  suddenly  to  39° 
or  41°  C.  (102°-106°  F.),  with  rigors.  We  have 
already  pointed  out  that  in  the  most  severe  cases,  in 
which  numerous  virulent  bacteria  remain  in  the 
blood,  the  body  is  only  able  to  offer  a  slight  degree 
of  resistance.  In  these  cases  there  is  no  fall  in  tem- 
perature and  no  formation  of  abscesses,  and  the 
infection  is  often  fatal  in  twenty-four  hours  or  a  few 
days,  with  high,  continued  fever. 

On  the  other  hand,  if  the  bacteria  only  enter  the 
blood  intermittently,  there  may  be  periods  during 
which  fever  is  absent  {e.g.  after  evacuation  of  retained 
virulent  secretion  by  incision).  With  fresh  infection 
of  the  blood  there  is  at  the  same  time  a  rise  of  tem- 
perature. Hence  the  variations  in  the  temperature 
chart.  Although  remissions  in  temperature  are  char- 
acteristic of  mild,  general  infection,  this  remittent 
fever  after  some  days  may  become  continuous  and 
fatal.  For  example,  when  an  extremity  has  been 
amputated  for  progressive  suppuration,  the  tempera- 
ture falls;  but  it  may  rise  again  after  a  time,  showing 
that  the  organism  was  already  saturated  with  bac- 
teria and  their  toxins,  and  that  the  operation  was 
performed  too  late  to  save  life.  It  is  noteworthy 
that  the  pulse  in  remittent  fever  remains  small  and 
rapid  during  the  fall  of  temperature,  even  after  com- 
plete cessation  of  the  fever,  showing  how  much  the 
heart  is  affected  by  the  process. 

If,  after  extensive  operative  interference,  the  tem- 
perature approaches  normal,  this  may  be  regarded 

266 


as  a  good  sign  for  the  further  progress  of  the  case. 
A  subnormal  temperature  is  sometimes  observed  in 
the  most  severe  cases  of  general  infection,  and  sig- 
nifies complete  collapse  of  the  organism. 

The  respiration  is  rapid,  as  in  all  feverish  condi- 
tions, and  may  become  stertorous  in  severe  cases 
with  loss  of  consciousness. 

Besides  sudden  rise  of  temperature  and  rapidity  of 
the  pulse,  the  tongue  shows  conditions  which  are 
characteristic  of  general  infection.  Changes  in  the 
tongue  are  observed  even  in  slight  disturbance  in  the 
wound.  The  tongue  is  at  first  smooth,  dry  and  sal- 
mon colored;  later  on  it  becomes  rough,  fissured  and 
brownish  black.  In  severe  cases  of  general  infection 
the  teeth  are  also  dry  and  coated  with  sordes.  The 
conjunctivae  are  yellow,  and  in  severe  cases  there 
may  be  jaundice  of  the  whole  body  (hematogenous 
icterus).  The  patients  are  continually  tormented  by 
sweating  and  thirst. 

These  characteristic  symptoms  are  diagnostic  of  a 
general  infection  whose  point  of  origin  is  concealed. 
On  the  other  hand,  in  general  infection  arising  from 
infected  wounds,  the  earliest  signs  pointing  to  gen- 
eral infection  are  often  observed  in  the  wound  itself. 
As  every  pyogenic  condition  may  lead  to  general 
infection,  the  wound  must  be  continually  watched 
by  frequent  changing  of  the  dressings.  The  expe- 
rienced can  often  foresee  the  onset  of  general  infec- 
tion, from  the  appearance  of  the  wound.  Apart  from 
cases  of  general  infection  following  a  slight  abrasion 
of  the  skin  or  mucous  membrane,  the  wound  generally 
becomes  painful  and  oedematous;  the  granulations 
become  unhealthy  and  flabby;  the  discharge  of  pus 
subsides  and  gives  place  to  a  scanty,  dii'ty,  often 
fetid  secretion;  the  surface  of  the  wound  l)ecomes 
dry  and  often  covered  by  diphtheroid  membrane 
(Fig.  101).  Retention  of  pus,  necrosis,  extension  of 
suppuration,  lymphangitis  and  lymphadenitis  are 
often  concomitant  signs.     In  infection  by  putrefactive 

267 


bacteria  (Fig.  109)  there  are  bullie  in  the  infiltrated 
skin  and  crepitation  due  to  the  formation  of  gas,  and 
bubbles  of  gas  in  the  secretion.  Unfortunately,  these 
characteristic  signs  are  often  overlooked;  operative 
interference  which  could  prevent  extension  of  the 
already  commencing  general  infection  is  neglected, 
and  the  condition  passes  into  a  stage  which  is  almost 
always  incurable. 

In  no  other  condition  is  the  organism  so  much 
altei'ed  as  in  advanced  general  infection,  so  that  the 
clinical  symptoms  become  indelibly  imprinted  on  the 
memory  of  the  observer.  All  the  already-mentioned 
symptoms  of  commencing  general  infection  become 
intensified  in  advanced  cases.  The  patients  at  first 
become  light-headed,  then  delirious,  and  finally 
unconscious.  The  indifference  of  patients  in  the 
advanced  stage  is  in  marked  contrast  to  their  feeling 
of  fear  in  the  early  stage  of  infection,  and  is  an  unfa- 
vorable sign.  In  the  final  stage,  shortly  before  death, 
if  the  patient  has  not  permanently  lost  consciousness, 
he  often  has  attacks  of  fear,  or  even  maniacal  attacks, 
followed  by  collapse.  In  this  stage  the  patient  can 
hardly  be  kept  in  bed,  as  he  makes  repeated  attempts 
to  go  home,  etc. 

The  gastro-intestinal  canal  is  severely  affected; 
vomiting  of  blood  from  submucous  hemorrhage, 
vomiting  of  bile  and  uncontrollable  diarrhea  result 
from  the  action  of  toxins.  The  skin  is  pale  and  cold, 
and  may  present  morbilliform  eruptions,  erythema, 
erysipelatous  reddening,  vesicular  eruptions,  puncti- 
form  hemorrhages  or  more  extensive  blood-effusions. 
Bedsores  are  also  common. 

Almost  all  the  internal  organs  are  saturated  with 
bacteria  and  their  toxins,  and  react  in  their  special 
manner.  Nephritis  is  manifested  by  albuminuria; 
meningitis  gives  rise  to  stiffness  of  the  neck;  pleuritis 
causes  blood-spitting;  pericarditis  is  manifested  by 
pericardial  friction,  and  endocarditis  (which  is  very 
common  and  often  ulcerative)  by  cardiac  murmurs. 

268 


As  in  every  severe  infection,  the  spleen  is  enlarged, 
and  sometimes  there  is  acute  bronchocele. 

In  streptococcal  general  infection  there  is  nearly 
always  suppuration  in  the  joints;  in  staphylococcal 
infection,  suppuration  in  the  bones.  Lastly,  infec- 
tive emboli  or  propagated  thrombo-phlebitic  abscesses 
(metastatic)  may  occur  in  all  the  organs,  especially 
in  staphylococcal  infection.  In  this  way  multiple 
abscesses  may  appear  in  the  skin.  Metastatic  ab- 
scesses may  be  cold  and  painless,  and  often  contain 
few  bacteria.  Deeply  situated  subfascial  and  inter- 
muscular abscesses  often  escape  observation.  Lastly, 
small  multiple  or  large  abscesses  may  occur  in  the 
lungs,  heart,  liver,  kidneys,  etc.  According  to  Wal- 
deyer,  these  abscesses  are  due  to  plugging  of  the 
smallest  vessels.  For  example,  plugging  of  the 
central  artery  of  the  optic  nerve  causes  panophthal- 
mitis, while  plugging  of  a  terminal  artery  in  the  lung 
causes  an  infarct.  In  this  advanced  stage  of  general 
infection,  there  is  often  frequent  bleeding  from  the 
wound  at  the  seat  of  the  local  infection,  due  to  affec- 
tion of  the  arteries.  In  the  pre-antiseptic  period 
many  cases  of  amputation  were  fatal  owing  to  this 
so-called  septic  secondary  hemorrhage.  In  this  stage 
bacteria  are  nearly  always  found  in  the  blood.  While 
an  increase  of  bacteria  in  the  blood  is  a  bad  sign, 
their  disappearance  is  not  always  a  good  sign  for  the 
further  progress  of  the  case;  for  after  the  disap- 
pearance of  bacteria  from  the  blood  in  many  diseases, 
the  action  of  their  toxins  (toxinsemia)  becomes  mani- 
fest. Streptococci  are  more  easily  demonstrated  in 
the  blood  than  staphylococci. 

According  as  the  onset  is  gradual  or  sudden,  and 
according  to  the  degree  and  the  course  of  the  general 
infection,  a  many-sided  but  unmistakable  clinical  pic- 
ture is  produced. 

The  chronic  forms  of  general  infection,  which  occur 
after  long-standing  fistulas,  suppuration  and  necrosis, 
are  characterized  Ijy  their  gradual  development  and  by 

369 


the  slight  severity  of  the  symptoms.  Many  cases, 
however,  are  fatal  from  heart  failure  or  albuminuria; 
or  the  chronic  form  may  become  acute.  In  chronic 
general  infection  there  are  often  long  periods  free 
from  fever,  followed  by  rigors  and  rise  of  temperature. 
In  the  chronic  forms  metastatic  abscesses  are  more 
common.  In  such  cases  recovery  may  take  place 
after  removal  of  the  primary  cause,  but  it  requires 
several  months  to  restore  the  weakened  body.  Again, 
acute  general  infection  may  become  chronic,  and 
occasionally  end  in  recovery. 

It  is  only  young  and  robust  bodies  that  can  offer 
an  effective  resistance  against  such  a  destructive  mor- 
bid condition,  and  then  only  in  the  early  stages  of 
infection.  The  organism  cannot  withstand  the  de- 
structive action  of  a  fully  developed  general  infection. 
These  cases  are  all  fatal.  Even  in  the  early  stages  of 
general  infection  the  heart  may  become  so  weak  by 
the  action  of  toxins,  that  death  occurs  from  collapse 
before  the  full  development  of  the  clinical  picture. 
Staphylococcal  infection,  with  its  tendency  to  metas- 
tatic formation  and  its  remittent  type  of  fever,  is  more 
likely  to  recover  than  streptococcal  infection;  this  is 
generally  fatal  in  a  few  days,  with  continued  fever 
and  increase  of  all  symptoms,  but  without  metastatic 
formation. 

Differential  Diagnosis.  Although  the  clinical 
symptoms  of  a  typical  case  of  general  infection  are 
unmistakable,  cases  in  which  the  origin  of  infection 
remains  unrecognized,  or  cases  of  chronic  general 
infection  may  be  mistaken  for  typhoid,  miliary  tuber- 
culosis or  acute  rheumatism.  Severe  inflammations, 
erysipelas  (especially  hemorrhagic  bullous  erysipelas) 
may  be  associated  with  such  high  temperature  and 
rigors,  etc.,  that  it  is  difficult  at  first  to  distinguish 
whether  the  symptoms  are  due  to  the  local  condition, 
or  to  the  commencement  of  general  infection.  The 
progress  of  the  disease  will  decide.     It  must,  how- 

270 


ever,  be  borne  in  mind  that  in  these  cases  there  is 
generally  already  commencing  general  infection, 
especially  in  cases  of  progressive  inflammation. 

Treatment.  Apart  from  cases  in  which  the  most 
acute  form  of  general  infection  arises  from  com- 
paratively slight  lesions,  some  cases  may  be  cured 
by  proper  treatment  of  infected  wounds  (Fig.  93), 
and  by  early  diagnosis  of  commencing  general  infec- 
tion. Special  attention  must  be  devoted  to  the  place 
of  entry  of  the  infection.  Free  incisions  are  here 
required.  Infected  joints  must  be  resected.  In 
some  cases  of  severe  general  infection  and  progressive 
suppuration  in  the  extremities,  amputation  should 
not  be  too  long  delayed. 

In  threatening  general  infection  from  purulent 
thrombo-phlebitis  of  the  large  veins,  ligation  should 
be  performed;  for  instance,  of  the  jugular  vein  and 
anterior  facial  vein  in  carbuncle  of  the  face;  of  the 
internal  jugular  vein  in  otitis  media.  Metastatic  ab- 
scesses must  be  opened  early.  Metastatic  joint  effu- 
sions should  be  incised.  Pleural  effusions  require 
aspiration  or  resection  of  the  ribs.  Suppuration  in 
the  internal  organs  (liver,  brain,  kidneys)  require 
operative  interference. 

Antipyretics  are  best  avoided  on  the  whole,  as  they 
obscure  the  symptoms  and  weaken  the  heart.  In 
severe  cases  high  temperature  may  be  reduced  by 
tepid  sponging.  The  heart  must  be  supported  by 
stimulants.  Nourishing  diet  is  required  (if  neces- 
sary by  esophageal  tube).  Subcutaneous  or  intra- 
venous injections  of  saline  solution  are  often  useful. 
Subcutaneous  injections  of  nucleinic  acid  with  salt 
solution  have  been  recommended.  Not  more  than 
two  hundred  to  three  hundred  cubic  centimeters  of 
solution  should  be  injected  at  one  time  into  the  veins. 
Injections  of  colloidal  silver,  anti-streptococcal  serum 
and  polyvalent  serum  (Aronsohn)  have  generally  no 

influence  on  the  disease. 

271 


On  account  of  the  danger  of  infection  to  others,  the 
patients  should  be  isolated  and  treated  by  special 
attendants.  The  body  must  be  frequently  bathed 
with  alcohol  or  spirit  of  camphor  to  prevent  the  for- 
mation of  bedsores,  especially  on  the  back  and  but- 
tocks. The  wound  at  the  seat  of  infection  must  be 
dressed  at  least  once  or  twice  a  day  to  prevent  accu- 
mulation of  pus.  Frequently  changed  moist  dress- 
ings are  the  best.  Iodoform  gauze  should  be  avoided, 
as  it  is  rapidly  decomposed  by  the  secretion  and  gives 
rise  to  toxic  symptoms.  Disinfection  of  the  wound 
with  strong  antiseptics  is  to  be  avoided  on  account  of 
its  injurious  effect  on  the  tissues.  The  affected  parts 
of  the  body  should  be  completely  immobilized.  Rub- 
ber gloves  should  be  worn  when  dressing  the  wounds, 
and  no  aseptic  operation  should  be  performed  on  the 
same  day  by  the  surgeon  who  dresses  them. 

After  recovery  from  general  infection  great  care 
must  be  taken  of  the  body,  in  order  to  give  encap- 
suled  traces  of  the  disease  an  opportunity  to  heal. 
These  encapsuled  metastatic  foci  may  at  any  time 
(even  after  some  years)  become  virulent  from  some 
exciting  cause,  and  give  rise  to  fresh  infection. 
Patients  often  succumb,  after  some  years,  to  nephri- 
tis, endocarditis,  pleurisy  or  pneumonia.  In  these 
cases  strychnine  is  useful. 

Fig.  108  shows  a  case  of  acute  general  infection 
arising  from  a  subcutaneous  whitlow,  which  was 
insufficiently  incised  and  extended  to  the  tendon- 
sheath  and  the  joint.  The  temperature  rose  to 
41°  C.  (106°  F.),  with  rigors;  remained  high  for  a  few 
days  and  then  became  remittent,  during  the  forma- 
tion of  several  subcutaneous  metastatic  abscesses. 
An  abscess  developed  gradually  in  the  thigh;  this 
was  incised,  and  thin  pus  containing  a  few  staphylo- 
cocci evacuated.  Staphylococci  were  also  present  in 
the  blood  for  some  time.  Other  symptoms  were — 
dry  tongue,  jaundice,  slight  delirium,  and  diarrhea. 


The  wound  in  the  finger  was  dry  and  unhealthy. 
After  disarticulation  of  the  finger  there  was  no  exten- 
sion of  infection  to  the  hand,  and  the  whole  condition 
improved.  Under  the  above-mentioned  treatment, 
with  injection  of  saline  solution,  etc.,  recovery  took 
place  in  a  few  months.  Several  metastatic  abscesses 
required  incision  during  the  course  of  the  disease. 
After  removal  of  the  finger,  bacteria  were  no  longer 
found  in  the  blood^a  proof  that  the  virulent  bacteria 
in  the  blood  were  derived  from  the  seat  of  infection. 
The  pulse  remained  rapid  for  a  long  time  after 
recovery. 


273 


GASPHLEGMONE  (Gaseotis  phlegmon) 
(EDEMA   MALIGNUM  (Malirjnant  (Edema) 
PHLEGMONE  EMPHYSEMATOSA— GANGRAENOSA 

{Gangrenous,  emphi/sematous  phlegmon) 
Plate  LXXXVII,  Fig.  109. 

We  have  already  mentioned  (Fig.  101)  the  pro- 
gressive putrefactive  inflammation  which  often  occurs 
in  necrosed  tissues,  and  in  the  wounds  of  diabetics. 
Similar  conditions  of  progressive  inflammation,  under 
various  names,  accompanied  by  rapid  necrosis  and 
the  formation  of  gases  in  the  tissues,  give  rise  to  gen- 
eral infection,  and  run  an  unfavorable  course. 

Pirogoff  described  these  cases  as  acute  purulent 
oedema,  Maisonneuve  as  fulminating  gangrene,  others 
as  gasphlegmon,  gangrenous  phlegmon,  etc.  The 
putrid  necrosis  of  wounds  known  as  "hospital  gan- 
grene," which  was  so  common  in  the  pre-antiseptic 
days,  appears  to  be  nothing  more  than  putrefactive 
inflammation  due  to  gas-forming  bacteria.  All  these 
conditions  are  best  included  under  the  name  jprogres- 
sive  gaseous  ^phlegmon.  The  causes  of  these  phleg- 
mons are  not  well  known,  as  they  are  anterobic 
bacteria  which  have  not  yet  been  well  differen- 
tiated from  each  other  by  bacteriological  methods. 
They  are  found  most  often  in  dust,  manure  and 
putrid  flesh. 

The  bacillus  of  malignant  oedema,  the  bacillus 
emphysematosus  and  the  proieus  vulgaris  are  the 
bacteria  at  present  found,  generally  in  symbiosis 
with  the  ordinary  pus-forming  bacteria,  especially 
streptococci.  By  this  symbiosis  the  growth  of  the 
anaerobic  bacteria  is  at  first  made  possible  in  open 
wounds,  and  through  the  combined  action  of  both 

274 


n 


5 
CI 


U) 


o 


to 


forms  of  bacteria  rapid  and  extensive  destruction  of 
tissue  may  be  caused.  Sometimes  gaseous  phlegmon 
is  found  after  quite  harmless  lesions  of  the  skin 
(Fig.  109),  also  after  compound  complicated  frac- 
tures with  small  wounds. 

Gaseous  phlegmons  occur  in  the  extremities;  on 
the  back,  in  connection  with  bedsores;  in  operative 
wounds  on  the  rectum,  through  infection  by  faeces; 
in  the  penis,  scrotum  and  perineum,  from  lesions  of 
the  urethra  with  extravasation  of  urine;  in  the  neck, 
after  lesions  of  the  esophagus  and  pharynx.  The 
progress  of  gaseous  phlegmon  is  extremely  rapid; 
in  a  few  hours  large  portions  of  the  body  are  affected 
by  the  rapid  formation  of  gas.  As  gaseous  phleg- 
mon may  occur  after  apparently  slight  injuries,  it 
is  necessary  to  emphasize  the  necessity  of  frequent 
dressings  in  order  to  control  the  progress  of  infection. 

The  wound  becomes  dry,  coated  and  fetid,  and 
extensive  swelling  rapidly  extends  from  it  on  all  sides. 
The  discharge  from  the  wound  is  brownish  or  green- 
ish, fetid,  and  mixed  with  necrotic  shreds  of  tissue. 
High  temperature,  rigors,  severe  pain,  anxiety  and 
later  on  delirium  and  frequent  pulse  indicate  the 
onset  of  general  infection. 

The  circulation  is  obstructed  by  the  great  pressure 
of  gas  in  the  tissues.  The  skin  of  the  extremities 
becomes  pale  and  cold,  and  presents  brown  and 
green  spots,  and  punctiform  hemorrhages.  Small 
vesicles  filled  with  dark  fluid  then  appear,  which  later 
on  become  larger;  finally  the  whole  epidermis  of  the 
affected  parts  is  raised,  and  underneath  it  is  offensive, 
dirty  fluid.  In  other  places  the  skin  is  reddish  brown, 
hard,  and  infiltrated.  There  is  no  formation  of  a 
circumscribed  fluctuating  collection  of  fluid,  but  the 
tissues  are  saturated  with  fetid,  sanious  fluid  contain- 
ing bubbles  of  gas.  On  pressure  the  characteristic 
crepitation  of  cutaneous  emphysema  is  heard.  The 
infiltration  is  seen  best  after  incision.  The  tissues 
cannot  be  distinguished  from  each  other — muscles, 

2r5 


fascia  and  periosteum  are  transformed  into  sodden, 
homogenous,  greenish  shreds.  If  the  medullary 
cavity  of  a  bone  is  opened,  it  is  filled  with  sanious 
fluid.  Sometimes  circumscribed  cavities  containing 
fluid  and  gas  are  found  under  the  skin.  Pressure  of 
gas  may  cause  gangrene  of  the  peripheral  parts  of 
the  extremities,  resembling  the  putrefaction  of  a 
corpse  (Fig.  109).  At  the  same  time  there  is  rapidly 
extending  lymphangitis,  in  the  form  of  reddish-blue 
or  reddish-brown  cords;  the  color  being  due  to  con- 
gestion in  the  tissues.  The  lymphatic  glands  are 
infiltrated  and  painful.  The  veins  are  aft'ected 
with  thrombo-phlebitis.  Finally,  the  arteries  are 
destroyed,  and  severe  hemorrhage  ensues.  The 
neighboring  joints  are  filled  with  sanious  fluid  {e.g. 
the  hip  joint  after  extravasation  of  urine. 

The  formation  of  gases  in  the  subcutaneous  tissue 
may  extend  to  large  portions  of  the  body ;  for  instance, 
from  the  neck  to  the  thorax  and  abdomen,  and  from 
the  coccyx  over  the  whole  of  the  back.  Death  gen- 
erally occurs  from  general  infection,  when  the  forma- 
tion of  gases  is  found  in  the  internal  organs  at  the 
autopsy.  Gaseous  phlegmon  in  the  neck  may 
cause  death  from  oedema  of  the  glottis  or  from 
mediastinitis.  In  spite  of  the  general  infection  bac- 
teria are  not  usually  found  in  the  blood. 


Differential  Diagnosis.  Gaseous  phlegmon 
in  the  early  stages  may  be  mistaken  for  progressive 
streptococcal  inflammation.  Hemorrhagic  bullous 
erysipelas  (Fig.  91)  and  anthrax  (Figs.  112  and  113) 
may  also  cause  great  swelling  of  the  skin  with  for- 
mation of  bullae.  However,  gaseous  phlegmon  is 
distinguished  from  the  above  by  its  rapid  course,  by 
the  necrosis  of  the  tissues,  by  the  fetid  secretion  con- 
taining gases,  and  by  the  crepitation  in  the  oede- 
matous  parts.  In  doubtful  cases  bacteriological 
examination  must  be  made. 

276 


Treatment.  Early  and  free  incisions  are  indi- 
cated to  open  up  the  tissues  and  de{)rive  the  anairobic 
bacteria  of  their  conditions  for  existence.  In  com- 
pound fractures  with  infection  of  the  bones  and 
joints,  amputation  is  necessary  to  save  life.  If  the 
gaseous  infiltration  has  already  extended  above  the 
seat  of  fracture,  amputation  may  be  performed  a 
short  distance  above  this  point,  and  the  infiltrated 
tissues  of  the  stump  freely  incised.  The  wound 
should  be  dressed  with  dry  aseptic  tampons  (not 
iodoform),  or  moist  dressings  with  mild  antiseptic 
lotions.     Disinfection  with  strong  lotions  is  injurious. 

In  extravasation  of  urine  external  urethrotomy  is 
required,  besides  free  incisions.  In  gaseous  phleg- 
mon of  the  neck  a  preliminary  tracheotomy  is  nec- 
essary before  making  incisions,  on  account  of  the 
danger  of  oedema  of  the  glottis. 

Fig.  109  shows  a  characteristic  case  of  gaseous 
phlegmon.  In  a  young  man  two  small  abrasions 
were  caused  by  a  meat-knife,  one  on  the  index  finger 
and  one  over  the  fifth  metacarpo-phalangeal  joint. 
In  a  few  hours  the  forearm  became  enormously 
swollen,  and  in  a  few  days  the  swelling  extended  over 
the  whole  arm.  The  patient  became  delirious  and 
finally  completely  comatose.  After  incision,  the  tis- 
sues were  found  infiltrated  with  fetid  sanious  fluid 
containing  numerous  necrotic  shreds.  The  elbow 
and  shoulder  joints  were  full  of  sanious  fluid.  The 
finsers  were  cold.  Bacteriological  examination 
showed  the  presence  of  putrefactive  bacteria  and 
streptococci.  There  were  no  bacteria  in  the  blood. 
There  were  the  usual  signs  of  severe  general  infec- 
tion (dry  tongue,  jaundice,  etc.).  In  spite  of  free 
incisions,  and  disarticulation  at  the  shoulder  joint  on 
the  third  day,  the  patient  died. 


277 


LYMPHADENITIS   (BUBO)   INGULNALIS  DIFFUSA 

(Diffuse  Inguinal  Adenitis  (Bubo) 
Plate  LXXXVIII,  Fig.  110. 

Pyogenic  affection  of  the  lymphatic  glands  has 
already  been  mentioned  in  the  case  of  glandular  in- 
flammation in  the  neck  (Fig.  102).  The  lymphatic 
glands  act  as  barriers  which  stop  the  bacteria  brought 
to  them  by  the  lymphatic  vessels  and  destroy  them, 
unless  they  are  too  numerous  and  virulent,  when  they 
become  themselves  affected.  Besides  the  common 
pyogenic  affections  of  the  glands  of  the  neck,  the 
axillary  and  inguinal  glands  are  often  affected.  The 
inflammation  may  be  acute  or  chronic.  Injuries, 
eczema,  and  pyogenic  affections  such  as  whitlow, 
abscess,  lymphangitis  or  erysipelas  may  give  rise  to 
an  acute  purulent  lymphadenitis  or  to  chronic  lymph- 
adenitis, usually  staphylococcal.  The  point  of  origin 
is  often  invisible,  for  a  small  excoriation  of  the  skin 
may  heal  before  the  lymphangitis  to  which  it  gives 
rise  becomes  apparent. 

Abscesses  of  unknown  origin  (e.g.,  in  the  abdominal 
wall)  generally  arise  from  suppurating  aberrant 
lymphatic  glands.  The  inguinal  glands  (inguinal 
bubo)  may  be  affected  after  ingrowing  toenails,  exco- 
riations (Fig.  110),  soft  chancre  or  gonorrhea.  In 
the  last  case  gonococci  are  found  in  the  pus. 

The  acute  forms  are  very  painful  and  prevent  move- 
ment of  the  limb.  The  skin  becomes  red,  and  is  at 
first  movable  over  the  inflamed  glands;  but  it  grad- 
ually becomes  infiltrated  and  bluish  red  in  color. 
Pyogenic  infection  of  the  lymphatic  glands  may  give 
rise  to  diffuse  suppuration  of  the  surrounding  tissue 
(periadenitis)  which  may  extend  rapidly  in  the  sub- 

278 


Bockenheinier,  Atlas. 


Tab.  LXXXVIII. 


F-ig.  110.     l.ymphadenitis  inguinalis  diffusa  (Bubo) 


Rrhman    f^nmn^nv      V»wf_Vrtrlf 


cutaneous  tissue,  both  superficially  and  deeply  (Fig. 
110).  In  this  form  there  are  rigors,  fever  and  consti- 
tutional disturbance.  More  often  the  inflammation 
is  localized  and  gives  rise  to  a  circumscribed  abscess 
(Fig.  114).  The  skin  becomes  thin  and  the  pus  is 
discharged  through  a  fistula.  After  this  the  pain 
subsides;  but  the  fistula  does  not  heal,  because  the 
whole  gland  is  generally  necrotic  and  is  gradually 
cast  off,  giving  rise  to  infection  of  the  neighboring 
lymphatic  glands  and  the  formation  of  multiple 
fistulas. 

Diffuse  suppurative  lymphadenitis  causes  still 
greater  destruction  for  there  is  not  only  necrosis  of 
the  glands  themselves  but  also  of  the  periglandular 
tissue,  and  even  of  the  subcutaneous  tissue  in  exten- 
sive cases.  Moreover,  burrowing  abscesses  may  de- 
velop in  remote  places;  for  instance,  in  the  pelvis 
after  inguinal  adenitis,  and  in  the  retro-pharyngeal 
tissue  after  cervical  abscesses.  Again,  general  infec- 
tion may  occur  from  thrombo-phlebitis  {e.g.,  from 
thrombo-phlebitis  of  the  pelvic  veins  after  inguinal 
bubo.  All  these  complications  can  be  avoided  by 
early  incision. 

In  the  chronic  forms  inflammatory  symptoms  are 
absent.  A  slightly  painful  thickening  develops  in  one 
or  more  glands,  after  long-continued  irritations,  in- 
flammation in  the  neighboring  parts,  eczema,  pedicu- 
losis, ulcers,  etc.  Finally,  a  small,  irregular,  movable 
swelling  is  formed  in  the  subcutaneous  tissue,  covered 
by  normal  skin.  Recovery  takes  place  after  removal 
of  the  cause;  but  in  long-standing  cases  a  perma- 
nent swelling  may  remain  (fibrous  hyperplasia). 

Differential  Diagnosis.  Acute  lymphadenitis 
is  characteristic  and  easy  to  diagnose  by  occurring 
in  the  situation  of  the  various  groups  of  lymphatic 
glands.  The  diagnosis  of  submaxillary  and  cervical 
lymphangitis  from  alveolar  periostitis,  dermoids, 
sebaceous  cysts  and  tuberculous  abscesses  has  al- 

279 


ready  been  given  (Fig.  10''2).  Acute  lymphangitis 
may  be  mistaken  for  sweat-gland  abscesses,  especially 
in  the  axilla,  but  these  are  usually  small,  multiple  and 
circumscribed.  In  the  inguinal  region  a  hernia  may 
be  mistaken  for  a  bubo,  especially  when  the  sac  of 
the  hernia  is  inflamed  and  is  situated  over  the  glands. 
This  error  is  more  likely  to  occur  in  incomplete  her- 
nias in  women.  In  these  cases  diagnosis  is  often  only 
made  after  incision.  Suppuration  arising  from  neigh- 
boring bones  or  joints  may  also  simulate  lymphade- 
nitis. Tuberculous  lymphangitis  may  cause  inflam- 
matory infiltration,  and  painful  enlargement  of  the 
glands  accompanied  by  fever;  but  the  glands  are 
softer  and  of  less  uniform  consistence.  If  a  fistula  is 
present  the  diagnosis  is  more  easy  (Fig.  125).  Tuber- 
culous abscess  is  of  slower  development,  and  is  gen- 
erally associated  with  various  degrees  of  infiltration 
of  neighboring  glands.  Lastly,  the  thin  greenish  pus 
is  characteristic. 

Chronic  lymphadenitis  may  be  mistaken  for  metas- 
tatic carcinomatous  disease  of  the  glands;  e.g.,  of  the 
inguinal  glands  after  cancer  of  the  anus.  These 
glands,  however,  are  hard  and  more  or  less  fixed. 
Syphilis  gives  rise  to  multiple  hard  infiltrations  of  the 
lymphatic  glands  in  various  parts  of  the  body. 

Treatment.  Pyogenic  infection  of  the  lymphatic 
glands  can  often  be  avoided  by  removal  of  the  pri- 
mary cause.  In  acute  lymphadenitis  early  incision 
will  prevent  the  complications  mentioned  above.  If 
this  is  neglected,  not  only  the  whole  of  the  lymphatic 
glands  of  the  aft'ected  region,  but  also  the  subcuta- 
neous tissue  may  undergo  necrosis;  also  oedema  or 
elephantiasis  of  the  extremity  may  develop,  owing  to 
the  obstruction  of  the  lymphatic  circulation.  Ele- 
phantiasis may  also  occur  after  total  extirpation  of 
the  lymphatic  glands  (Fig.  71).  This  may  be  avoided 
by  taking  care  not  to  remove  too  much  of  the  fatty 
connective  tissue  along  with  the  glands;    this  tissue 

280 


carries  on  the  lymphatic  circulation  after  removal  of 
the  glands,  and  new  glands  are  also  formed  from  it. 
In  the  groin  and  axilla  a  careful  dissection  of  the 
glands  must  be  made,  avoiding  the  great  vessels. 

Circumscribed  abscesses  are  best  opened  by  a  free 
incision.  Treatment  by  poultices  or  icebags,  aspira- 
tion, puncture  and  injection  of  various  fluids,  mas- 
sage and  inunction  of  mercurial  ointment  are  best 
avoided.  The  affected  parts  should  be  immobilized 
to  prevent  extension  of  the  infective  process.  Patients 
should,  therefore,  stay  in  bed.  Commencing  infec- 
tion of  the  lymphatic  glands  often  undergoes  sponta- 
neous resolution.  Acute  lymphadenitis  of  the  neck 
caused  by  infections  such  as  diphtheria,  may  subside 
spontaneously;  so  may  chronic  lymphangitis  when 
it  is  not  of  too  long  standing,  and  when  the  cause  is 
removed.  Inunction  with  iodide  of  potassium  or 
iodine-vasogen  ointments  is  useful  in  chronic  lymph- 
angitis. In  cases  of  large  glands  causing  pain,  or  of 
multiple  fistulas  connected  with  chronic  lymphade- 
nitis, the  glands  should  be  extirpated,  and  the  wounds 
plugged  for  a  long  time  with  iodoform  gauze  to  pre- 
vent relapse. 

Fig.  110  shows  a  case  of  acute  lymphadenitis  of 
the  inguinal  region,  occurring  after  an  excoriation  of 
the  skin  of  the  thigh,  which  has  already  scabbed  over. 
Infiltration  of  the  skin  and  subcutaneous  tissue 
extends  from  the  genito-crural  fold  down  the  thigh. 
The  symptoms  were  pain  and  difficulty  in  walking, 
followed  by  fever  and  rigors.  Under  an  anaesthetic 
an  incision  was  made  below  and  parallel  to  PouparVs 
ligament.  The  inguinal  glands  were  swollen,  and 
contained  numerous  foci  of  suppuration;  but  there 
was  no  extensive  necrosis,  nor  any  large  collection  of 
pus.  The  wound  was  j)lugged  with  iodoform  gauze 
and  the  leg  immobilized  on  a  splint.  The  wound 
healed  after  a  part  of  the  gland  which  had  necrosed 
came  away. 

281 


ARTHRITIS  GONORRHOICA  PHLEGMONOSA 

{Phlegmonous  Gonorrheal  Arthritis) 
Plate  LXXXIX,  Fig.  111. 

In  the  course  of  both  acute  and  chronic  gonorrhea 
the  joints  may  be  affected  by  general  gonococcal  in- 
fection of  the  blood.  In  the  acute  stage  of  gonorrhea, 
arthritis  may  be  caused  by  the  passage  of  bougies  or 
by  overexertion,  etc.  In  women  it  may  occur  during 
pregnancy.  In  chronic  gonorrhea  it  may  be  caused 
by  sexual  excess.  Gonococci  may  remain  for  a  long 
time  in  a  latent  state  encapsuled  in  the  mucous  mem- 
brane, and  when  set  free  by  mechanical  irritation  may 
again  become  virulent.  Recurrence  of  gonorrheal 
arthritis  may  take  place  in  cases  of  neglected  gonor- 
rhea, also  after  a  fresh  attack  of  gonorrhea. 

Through  invasion  of  the  joints  by  the  gonococci 
and  their  toxins  inflammation  is  set  up  which  may 
be  serous,  fibrinous  or  purulent.  Most  commonly 
the  arthritis  is  fibrinous,  suppurative  arthritis  being 
rare  and  generally  caused  by  mixed  infection.  One 
or  several  joints  may  be  affected  at  the  same  time,  or 
successively.  Acute  gonorrheal  arthritis  is  very  sud- 
den in  its  onset,  and  characterized  by  severe  pain, 
preventing  any  movement  of  the  affected  joint.  In 
a  few  hours  the  soft  parts  become  infiltrated  and 
cedematous,  the  infiltration  remaining  more  or  less 
limited  to  the  region  of  the  joint,  or  spreading  to  the 
neighboring  muscles  and  tendons.  The  skin  is  red 
and  tense  (Fig.  111).  In  severe  cases  there  is  high 
fever  and  complete  loss  of  function.  In  chronic 
gonorrheal  arthritis  there  are  usually  aching  pains 
in  the  joint  befoi'e  the  arthritis  becomes  evident. 

282 


Bockenheimer,  Atlas. 


Tab.  LXXXIX. 


Fig.  111.     .Artiiiitis  gonorrhoica  phlcgmonosa. 


The  knee  joint  is  most  often  affected  in  men;  the 
elbow  and  wrist  in  women.  The  hip,  ankle  and 
temporo-maxillary  joints  are  also  often  affected. 

In  cases  of  serous  or  sero-fibrinous  effusion,  limited 
to  the  joint,  the  swelling  generally  subsides  in  one  or 
two  weeks,  and  recovery  takes  place  without  loss  of 
function.  In  the  more  common  form  of  fibrinous 
arthritis,  however,  the  process  is  more  severe,  espe- 
cially when  the  infiltration  extends  to  the  periarticular 
tissue  and  the  soft  parts.  In  these  cases  the  arthritis 
is  accompanied  by  fever  and  rigors,  and  there  is  sero- 
fibrinous effusion  into  the  neighboring  parts,  but  no 
formation  of  pus.  The  inflammation  affects  not  only 
the  synovial  membrane,  but  may  cause  destruction  of 
the  cartilage  and  extend  to  the  bone.  This  may  result 
in  fibrous,  cartilaginous  or  bony  anchylosis  (X-ray 
examination).  Destruction  of  the  capsule  of  the 
joint  may  cause  subluxations  or  dislocations,  and  the 
prolonged  immobility  may  lead  to  muscular  atrophy. 

In  the  rarer  forms  of  suppurative  arthritis  there  is 
continued  high  fever  with  rigors,  and  severe  consti- 
tutional disturbance.  The  skin  is  red  and  there  is 
great  swelling  of  the  affected  parts. 

If  several  joints  are  affected  different  forms  of  gon- 
orrheal arthritis  may  occur  in  the  various  joints. 
Multiple  relapsing  arthritis  may  reduce  the  patients 
to  a  deplorable  condition,  as  they  often  cannot  walk 
or  use  their  arms.  Such  cases  may  be  fatal  from 
gradual  exhaustion. 

Differential  Diagnosis.  Gonorrheal  arthritis 
may  be  mistaken  for  acute  rheumatism;  but  the  latter 
usually  affects  a  greater  number  of  joints,  and  the 
acute  stage  of  inflammation  is  not  so  prolonged  as  in 
gonorrheal  arthritis.  Purulent  gonorrheal  arthritis 
must  be  diagnosed  from  other  suppurations  in  joints 
by  the  history,  by  the  presence  or  history  of  acute  or 
chronic  gonorrhea,  or  by  bacteriological  examination 
after  puncture  of  the  joint. 

283 


Chronic  gonorrheal  arthritis  is  often  difficult  to 
distinguish  from  certain  forms  of  syphilitic  arthritis, 
especially  when  both  diseases  have  been  contracted 
together. 

Tuberculous  arthritis  is  usually  easy  to  distinguish 
by  its  characteristic  signs  (Fig.  125). 

Treatment.  On  account  of  the  severity  of  the 
disease  and  the  possibility  of  a  fatal  ending,  espe- 
cially from  endocarditis,  the  prophylactic  treatment 
of  gonorrhea  is  important.  Washing  immediately 
after  coitus,  vaginal  injections  in  women,  the  instilla- 
tion of  a  few  drops  of  weak  silver  nitrate  solution  into 
the  urethra  after  coitus,  and  the  avoidance  of  any 
kind  of  irritation  (alcohol,  etc.),  will  often  prevent 
gonorrheal  infection.  Gonorrhea  should  be  regarded 
as  a  serious  disease  and  treated  accordingly.  In  gon- 
orrheal arthritis  the  urethra  should  always  be  exam- 
ined, and  treated  if  gonorrheal  urethritis  is  present. 

The  subacute  or  serous  forms  of  gonorrheal  arthri- 
tis subside  in  one  or  two  weeks  after  rest  in  bed;  but 
too  early  movement  may  cause  relapse.  In  fibrinous 
arthritis,  on  the  other  hand,  too  long  immobilization 
may  lead  to  anchylosis.  Immobilization  (by  plaster 
of  Paris  bandages,  or  better  by  extension  splints) 
should,  therefore,  not  be  continued  longer  than  one 
or  two  weeks;  after  which  gentle  massage,  active  and 
passive  movements  or  hot  air  treatment  should  be 
tried.  Langenbeck  has  recommended  "animal  baths" 
for  cases  of  stiffness;  i.e.,  placing  the  affected  part  in 
the  viscera  of  a  freshly  killed  animal,  to  obtain  the 
effect  of  animal  heat.  Sandbaths  are  also  worth  a 
trial.  If  an  acute  relapse  occurs  in  the  course  of  the 
disease  the  joint  must  be  again  immobilized.  In  any 
case,  movements  of  the  joint  must  be  carried  out  after 
two  or  three  weeks;  otherwise  bony  anchylosis  may 
occur.  Injections  of  morphine  may  be  given  before 
the  performance  of  massage  or  passive  movements, 
or  cocaine  may  be  injected  into  the  joint  (0.05  cubic 

284 


centimeters  of  a  five  per  cent,  solution).  Injections 
of  carbolic  acid  and  protargol  solution  into  the  joint 
have  also  been  recommended.  The  best  method  of 
treatment  would  be  injection  of  antitoxin,  as  the 
inflammation  is  primarily  caused  by  the  gonotoxin. 

[In  one  case  a  good  result  was  obtained  by  injection 
of  meningococcus-serum  Bockenheimer.] 

By  careful  after-treatment  complete  function  can 
generally  be  restored  even  in  severe  forms  of  gonor- 
rheal arthritis. 

Bier's  treatment  by  passive  hyperaemia  has  a  good 
effect  in  these  cases,  and  may  be  tried  in  all  cases  of 
gonorrheal  arthritis  where  there  is  no  suppuration. 
After  application  of  the  elastic  bandages,  the  joints 
become  painless  (in  about  fifty  per  cent,  of  cases),  so 
that  the  patients  do  not  hold  them  so  stiffly,  and  early 
movements  can  be  performed,  thus  giving  a  better 
functional  result.  In  severe  cases  the  joints  should 
be  bandaged  to  protect  them  against  injury,  the  ban- 
dages being  frequently  removed  and  movements  per- 
formed. The  elastic  compression  bandages  should 
be  applied  at  first  for  two  or  three  hours,  later  on  for 
twenty  hours.  This  treatment  may  be  carried  out 
without  danger  in  out-patient  practice  (polyclinic). 

If  there  is  much  destruction  of  the  joint,  with  sub- 
luxation or  anchylosis  in  a  faulty  position,  resection 
may  be  required.  Fibrous  contractures  are  common 
after  gonorrheal  arthritis;  these  can  be  corrected 
under  an  anaesthetic,  and  that  function  restored  bv 
appropriate  after-treatment.  In  suppurative  arthri- 
tis, which  is  often  complicated  by  lymphangitis, 
lymphadenitis  and  other  pyogenic  conditions,  arthrot- 
omy  or  resection  of  the  joint  must  be  performed  to 
avoid  general  infection.  These  cases  require  longer 
immobilization  of  the  joint. 

Fig.  Ill  shows  a  case  of  acute  and  painful  swelling 
in  the  region  of  the  wrist  joint  in  a  woman.  The  skin 
was  red  and  tense.     The  swelling  rapidly  extended 

285 


to  the  forearm  and  to  the  fingers,  so  that  the  patient 
could  not  use  the  arm.  The  wrist  joint  and  the  meta- 
carpo-phalangeal  joints  could  not  be  moved.  Exam- 
ination of  the  genitals  showed  gonorrhea.  On  the 
following  day  the  joint  effusion  increased  and  was 
partly  evacuated  by  puncture.  Gonococci  were  found 
in  the  fluid.  Under  treatment  by  passive  hypersemia 
the  pain  subsided  in  a  few  days  and  the  acute  inflam- 
mation became  chronic.  Massage,  active  and  passive 
movements,  combined  with  passive  hypersemia, 
restored  the  function  in  four  weeks. 


286 


Bockenheimer,  Atlas. 


Tab.  \C. 


Fig.  112.    Antlira.x         Pustuia  maligna. 


Rcbman  Company,  iS'ew-Vork. 


ANTHRAX  —  PUSTULA  MALIGNA 

(Anthrax — Malignant  Pustule) 
Plate  Xr,  Fig.  11-2. 

ANTHRAX  —  NECROSIS   (Anthrax  necrosis) 
Plate  XCI,  Fig.  113. 

Anthrax  (splenic  fever)  is  a  bacterial  disease  which 
occurs  externally  on  the  skin,  and  internally  in  the 
lungs  and  alimentary  canal.  The  bacteria  have  a 
characteristic  appearance.  They  consi.st  of  immo- 
bile rods  (bacilli)  with  sharp,  angular  corners,  and 
are  often  arranged  in  a  row  in  long  chains.  In  the 
center  of  the  rods  are  clear  spaces  corresponding  to 
spores,  which  are  very  resistant  to  dryness  and  heat. 
The  anthrax  bacillus  was  carefully  studied  by  Koch, 
while  Pasteur  originated  the  protective  inoculation  of 
animals  with  attenuated  cultures.  The  bacilli  and 
spores  are  found  in  the  alimentary  canal  of  animals 
(horses  and  cattle) ;  also  in  damp  soil  on  which  these 
animals  graze,  and  in  the  skin,  fur  and  excrements  of 
animals  infected  with  splenic  fever  (Rinderpest  or 
cattle  fever).  Epidemics  of  anthrax  are  common  in 
Egypt,  as  the  excrements  of  animals  are  used  as  fuel 
for  cooking  purposes.  The  disease  is  common  in 
Siberia  in  the  skin  trade  and  is  known  as  Siberian 
plague.  Butchers,  skinners,  ragsorters,  tanners, 
paper  makers  and  workers  in  horsehair  are  liable  to 
anthrax  infection.  The  disease  has  been  observed 
in  farmers,  owing  to  the  custom  of  treating  horses  and 
cows  affected  with  colic  by  passing  the  hand  into  the 
rectum.  The  disease  may  also  be  transmitted  by 
earthworms  and  flies.  The  bacilli  may  remain  local- 
ized at  the  seat  of  infection,  or  may  enter  the  blood- 
stream and  give  rise  to  metastatic  foci  in  other  places ; 
while  their  toxins  play  a  subordinate  part. 

287 


The  external  form  of  anthrax  occurs  on  the  skin  of 
the  neck  or  face  after  small  abrasions  of  the  skin, 
through  which  the  bacilli  enter.  The  infection  may 
be  conveyed  to  the  mouth  by  the  finger,  and  the 
spores  may  thus  be  inhaled  or  swallowed,  and  give 
rise  to  anthrax  of  the  lung  or  intestines  respectively. 

Anthrax  of  the  skin  has  a  very  characteristic  ap- 
pearance. A  small,  red  spot  first  appears,  with  fever 
and  often  rigors;  this  develops  into  a  small  vesicle 
with  yellowish  or  turbid  fluid  containing  anthrax 
bacilli  (malignant  pustule).  The  pustule  ruptures 
and  is  replaced  by  a  scab.  At  the  same  time  the  sur- 
rounding skin  becomes  green — a  sign  of  commencing 
necrosis.  The  early  appearance  of  necrosis  of  the 
skin  is  characteristic  of  anthrax  (Fig.  112).  The 
tissues  become  infiltrated  in  the  same  way  as  in  car- 
buncle (cf.  Fig.  89),  and  oedema  occurs  where  the 
skin  is  loosely  attached  to  the  subcutaneous  tissue 
{e.g.  eyelids).  The  redness  of  the  skin  extends  rap- 
idly and  irregularly,  resembling  erysipelas.  Other 
vesicles  appear  and  rupture,  after  which  there  is 
extensive  necrosis  of  the  skin  (Fig.  113). 

In  the  extremities,  along  with  the  above  symptoms, 
there  is  always  lymphangitis  and  lymphadenitis, 
which  may  form  abscesses  by  mixed  infection. 
There  is  always  considerable  constitutional  disturb- 
ance, with  fever,  rigors,  headache  and  rapid  pulse. 
Multiplication  of  the  bacilli  in  the  blood  gives  rise 
to  symptoms  of  general  infection — dry  tongue,  jaun- 
dice, diarrhea  and  swelling  of  the  spleen.  Death  may 
result  from  collapse  in  a  few  days. 

External  anthrax  has  a  more  favorable  prognosis 
than  internal  (mortality  twenty-five  per  cent.),  but 
anthrax  of  the  face  is  very  dangerous.  The  more 
marked  are  the  local  symptoms  the  more  likely  is 
general  infection.  Moreover,  anthrax  of  the  face 
may  easily  infect  the  mouth,  and  thereby  cause  infec- 
tion of  the  lungs  or  alimentary  canal.  In  the  milder 
forms  of  general  infection  metastatic  inflammations 

288 


are  caused  by  emboli  in  the  skin,  lungs,  alimentary 
canal  and  brain;  giving  rise  to  pleurisy  and  pneu- 
monia, ulcers  of  the  gut,  peritonitis  and  meningitis, 
which  are  generally  fatal.  Primary  internal  anthrax 
may  also  cause  secondary  infection  of  the  skin  by 
metastatic  deposits. 

The  usual  form  of  internal  anthrax  is  that  affecting 
the  intestine,  caused  by  infection  from  the  mouth; 
by  bacilli  conveyed  by  the  finger,  or  by  eating  the 
flesh  of  infected  animals.  This  gives  rise  to  hem- 
orrhagic ulceration  of  the  small  intestine,  with  a 
tendency  to  gangrene.  About  eighty  per  cent,  of 
cases  are  fatal  from  peritonitis  or  general  infection. 
Bacilli  are  found  in  the  stools. 

In  the  lungs  anthrax  is  more  rare  and  is  caused 
primarily  by  inhalation  of  the  spores.  It  occurs 
among  manufacturers  of  paper  and  horsehair  and 
among  ragsorters,  sometimes  in  an  epidemic  form. 
The  patients  are  suddenly  attacked  with  symptoms 
of  pneumonia  and  high  fever.  The  sputum  is  blood- 
stained and  contains  anthrax  bacilli.  About  eighty- 
nine  per  cent,  of  these  cases  are  fatal  from  pulmonary 
cedema  and  pleurisy. 

Both  external  and  internal  anthrax  may  occur 
simultaneously,  and  the  disease  is  then  almost 
always  fatal  from  general  infection. 

Differential  Diagnosis.  Pyogenic  infections, 
such  as  virulent  streptococcal  or  putrefactive  inflam- 
mations (cf.  Fig.  109),  and  hemorrhagic  bullous 
erysipelas  may  cause  the  formation  of  bullae  on  the 
skin,  and  mav.  therefore,  be  mistaken  for  anthrax; 
but  these  affections  run  a  different  course  and  do  not 
lead  so  quickly  to  necrosis  of  the  skin.  Glanders  also 
gives  rise  to  the  formation  of  bullae  and  gangrenous 
ulceration,  but  the  characteristic  carbuncular  infil- 
tration of  anthrax  is  absent.  In  doubtful  cases 
anthrax  bacilli  must  be  looked  for  in  the  fluid 
of  the  bullae.     This   is  especially  important,  as  the 

289 


treatment    of    anthrax    differs    from    that    of    the 
above-mentioned   affections. 

Treatment.  Prophylactic  treatment  consists  in 
strict  supervision  of  trades  in  which  there  is  a  danger 
of  anthrax  infection.  Skins  of  animals  should  be 
disinfected,  and  workmen  should  be  warned  of  the 
danger  of  infecting  the  mouth  from  handling  skins, 
rags,  horsehair,  etc.,  especially  during  meals. 

The  less  the  local  infection  is  irritated,  the  less  is 
the  danger  of  the  bacilli  entering  the  blood.  For 
this  reason  both  incisions  and  the  thermo-cautery  are 
contra-indicated,  as  they  often  cause  extension  of  the 
infiltration  or  even  general  infection  {von  Bergmann). 
Scabs  and  necrosed  tissue  must,  therefore,  be  left  to 
separate  spontaneously.  The  infected  area  should 
be  dressed  with  ointment  to  prevent  auto-infection  of 
the  patient.  If  the  disease  occurs  in  the  extremities 
they  must  be  fixed  on  splints.  Abscesses  in  the 
lymphatic  vessels  and  glands  caused  by  mixed  infec- 
tion must  be  opened.  Extensive  necrosis  of  the  skin 
sometimes  necessitates  a  plastic  operation  (Fig.  113). 
As  in  other  infective  diseases,  nourishing  diet,  stimu- 
lants, absolute  rest  and  isolation  are  required.  In 
severe  cases  the  injection  of  Sclavo's  serum  in  the 
region  of  the  infected  area  is  recommended. 

Fig.  112  shows  a  case  of  external  anthrax  in  a 
tanner,  which  developed  after  a  slight  abrasion  of 
the  skin.  It  began  as  a  red  papule,  followed  by  sev- 
eral vesicles  full  of  yellow  fluid  containing  anthrax 
bacilli.  At  the  same  time  there  was  erysipelatous 
reddening  of  the  skin,  carbuncular  infiltration  of  the 
tissues,  and  oedema  of  the  eyelids.  The  vesicle  at 
the  point  of  infection  ruptured  and  was  replaced  by 
a  scab,  round  which  the  skin  gradually  became  gray 
and  necrotic.  Fever  and  rigors  set  in,  and  the  disease 
spread  to  the  eyelids.  Fresh  vesicles  appeared,  with 
further  gangrene  of  the  skin  after  their  rupture.    The 

290 


Bockenheimer,  Atlas. 


Tab.  XCI. 


Fig.  113.    Antlirax  —   Necrosis. 


Rfbman  Company,  New- York. 


affected  area  was  covered  with  ointment  and  the 
symptoms  gradually  subsided,  without  internal  an- 
thrax or  general  infection  supervening. 

Fig.  113  shows  the  same  case  a  few  weeks  after 
infection.  The  leathery,  blackened,  necrosed  skin  is 
separated  by  a  zone  of  pus  and  slimy  granulation 
tissue  from  the  surrounding  skin,  which  is  still  red 
and  infiltrated.  The  necrosed  skin  is  firmly  adherent 
to  the  subjacent  tissues.  Removal  of  this  by  the 
knife  or  sharp  spoon  would  only  cause  a  further  out- 
break of  infection.  It  was,  therefore,  allowed  to  sep- 
arate gradually  under  treatment  by  moist  dressings  of 
peroxide  and  boric  acid  and  ointments.  In  this  case, 
after  separation  of  the  necrosed  skin,  the  defect  was 
repaired  by  a  plastic  operation,  and  the  upper  eyelid 
restored  by  a  pedunculated  flap.  The  patient  recov- 
ered, in  spite  of  the  unfavorable  prognosis  in  anthrax 
of  the  face  and  the  severity  of  the  local  infection. 


291 


LYMPHADENITIS  CIRCUMSCRIPTA  ABSCEDENS 

(Circum.scribed  suppurative  lymphadenitis) 
Plate  XCn,  Fig.  114. 

In  this  case  a  circumscribed  abscess  formed  in 
the  lymphatic  glands  behind  the  ear,  as  the  result 
of  pediculosis  of  the  scalp.  The  skin  was  red  and 
thin  at  apex  of  the  swelling.  Fluctuation  was  pres- 
ent. There  was  no  fever  nor  constitutional  dis- 
turbance. The  submaxillary  lymphatic  glands  were 
enlarged  and  slightly  painful  on  pressure.  The 
abscess  was  incised,  and  the  submaxillary  glands 
inuncted  with  iodide  of  potassium  ointment.  Heal- 
ing took  place  in  a  short  time. 

The  figure  shows  the  gluing  together  of  the  hairs 
and  the  punctiform  deposits  on  them  (nits)  due  to 
pediculosis.  The  frequent  irritation  has  caused 
eczema  of  the  scalp.  Infection  of  the  lymphatic 
glands  is  caused  by  infection  through  scratches. 
The  treatment  consists  in  removing  the  cause  {i.e. 
the  pediculosis)  by  rubbing  in  ten  per  cent,  naphthol 
ointment.  The  nits  can  be  removed  by  washing  with 
soft,  green  soap,  weak  liquor  potassse  or  weak  acetic 
acid  and  subsequent  combing.  The  eczema  gen- 
erally disappears  when  the  pediculosis  is  cured.  The 
prophylactic  treatment  of  pediculosis  consists  in 
cleanliness. 


292 


Bockenheimer,  Atlas. 


Tab.  XCII. 


W) 


•a 


to 


l^f.Km'.n     i"» 


Actinomycosis 

ACTINOMYCOSIS  INCIPIENS   {Incijnent  AcHnomycods) 

Plate  XCII,  Fig.  115. 
ACTINOMYCOSIS  PROGRESSIVA  {Progressive  Actirumycosis) 

Plate  XCm,  Fig.  116. 

Actinomycosis  is  a  chronic  infective  disease  caused 
by  a  fungus  (actinomyces) ,  which  is  called  the  ray- 
fungus  on  account  of  the  radiating  arrangement  of 
its  mycelium.  Actinomycosis  was  first  described  by 
Langenbeck,  and  later  by  Bollinger,  in  the  form  of 
new  growths  in  the  lower  jaw  of  cattle  and  horses. 
In  1878  Israel  found  yellow  bodies  in  the  pus  from  a 
patient  who  was  supposed  to  have  died  of  chronic 
pyaemia;  the  yellow  bodies  were  found  to  be  actino- 
myces. Later  researches  have  shown  that  there  are 
different  forms  of  actinomyces.  The  fungus  is  best 
stained  with  Levaditi's  silver  nitrate  method. 

The  fungus  is  found  in  corn,  straw  and  flour.  In 
countrymen  who  have  the  habit  of  chewing  corn  the 
mouth  may  become  infected;  either  through  a 
carious  tooth,  leading  to  infection  of  the  bone,  or 
through  the  parotid  duct,  leading  to  infection  of  the 
cheek.  In  the  great  majority  of  cases,  therefore,  we 
find  actinomycosis  in  the  mucous  membrane  of  the 
cheek,  the  tongue,  the  jaw,  the  pharynx  and  the  neck. 
It  forms  a  stringy,  nodular  infiltration  which,  by  be- 
coming confluent,  causes  a  swelling  of  wooden  hard- 
ness. Acute  inflammatory  symptoms  are  absent. 
The  skin  becomes  bluish  red  when  the  infiltration 
extends  through  the  cheek  or  into  the  neck  (Figs. 

293 


115  and  116).  The  infiltration  extends  gradually  into 
the  neighboring  tissues,  and  by  its  unlimited  progress 
resembles  a  malignant  tumor.  At  the  same  time 
there  is  softening  in  the  center  of  the  infiltration  with 
the  formation  of  an  abscess  which  discharges  through 
several  ramifying  and  anastomosing  fistulas.  The 
pus  contains  the  characteristic  yellow  bodies,  about 
the  size  of  a  pin's  head.  There  is  much  induration 
around  the  fistulas  which  often  prevents  the  discharge 
escaping.  Granulation  tissue  is  scanty,  yellowish 
red  in  color,  and  rapidly  disintegrated.  The  forma- 
tion of  abscesses  is  accompanied  by  a  slight  rise  of 
temperature.  Large  abscesses  may  result  from  mixed 
infection;  the  yellow  bodies  are  then  often  absent, 
the  fungus  being  destroyed  by  the  pus  cocci. 

In  actinomycosis  of  the  cheek  a  fistula  is  formed 
externally.  If  the  infiltration  is  situated  in  the  mas- 
ticatory muscles  there  is  trismus.  The  fungus  may 
extend  to  the  bones  and  give  rise  to  enormous  tumors. 
If  the  upper  maxilla  is  invaded  it  may  extend  to  the 
base  of  the  skull  and  lead  to  meningitis  or  cerebral 
abscess.  If  the  tongue  is  infiltrated  it  cannot  be 
moved.  When  actinomycosis  extends  to  the  root  of 
the  tongue  or  to  the  pharynx  there  is  difficulty  in 
swallowing  and  later  on  in  breathing.  In  these  cases 
abscesses  form  which  generally  discharge  through 
fistulas  in  the  neck,  and  give  rise  to  secondary'  actino- 
mycosis of  the  skin.  Primary  actinomycosis  of  the 
skin  has  been  observed  through  infection  through 
lesions  of  the  skin  (vo7i  Bergmann). 

The  prognosis  of  actinomycosis  of  the  buccal 
cavity  is  comparatively  favorable,  and  by  appropriate 
treatment  two-thirds  of  the  cases  recover.  On  the 
other  hand,  by  extension  to  the  retropharyngeal  tissue 
it  may  descend  to  the  thorax  or  abdomen.  Inspira- 
tion of  secretion  containing  the  fungus  may  infect  the 
lunss.  Invasion  of  the  larwe  veins  of  the  neck  result- 
ing  in  metastatic  foci  has  also  been  observed.  From 
this  circumstance  the  affection  was  formerly  regarded 

294 


as  chronic  pyaemia  especially  as  actinomycotic  gen- 
eral infection  gives  rise  to  similar  clinical  appearances 
and  eventually  causes  death  by  cachexia. 

Actinomycosis  of  the  lungs  may  occur  from  direct 
inspiration  of  substances  carrying  the  fungus,  besides 
infection  from  actinomycosis  of  the  mouth.  The 
prognosis  is  very  bad.  The  symptoms  are  those  of 
commencing  phthisis.  The  lung  becomes  indurated 
and  the  pleura  infiltrated,  and  abscesses  discharge 
through  the  skin  of  the  thorax.  The  disease  may 
spread  from  the  pleura  to  the  pericardium,  the  ver- 
tebrae, the  diaphragm  and  the  abdominal  cavity 
The  patient  becomes  exhausted  from  empyema  and 
multiple  burrowing  abscesses.  The  fistulas  are  diffi- 
cult to  follow  owing  to  the  hardness  of  their  walls,  so 
that  relapses  are  common  after  incision,  and  the  cases 
are  usually  fatal.  Cases  of  recovery  from  actinomy- 
cosis of  the  lung  have,  however,  been  observed. 
Infiltration  of  wooden  hardness  between  the  ribs  is 
always  suggestive  of  actinomycosis. 

The  intestine  may  also  be  the  seat  of  actinomycosis 
when  material  containing  the  fungus  is  swallowed. 
The  ileo  csecal  region  is  the  part  most  often  affected, 
in  the  form  of  hard  tumor-like  infiltration  which  may 
be  so  extensive  as  to  prevent  the  passage  of  faeces. 
The  disease  may  spread  to  the  vertebrae,  pelvic  bones, 
abdominal  organs,  and  may  extend  through  the  dia- 
phragm to  the  thorax.  There  is  often  secondary 
actinomycosis  of  the  skin.  A  fistula  often  forms  near 
the  umbilicus,  discharging  pus  and  sometimes  faeces. 
The  prognosis  is  somewhat  more  favorable  than  that 
of  actinomycosis  of  the  lung,  but  cases  are  often  fatal 
from  general  infection. 

\\Tien  actinomycosis  is  visible  externally  the  diag- 
nosis is  not  usually  difficult;  the  wooden  infiltration, 
the  multiple  fistulas,  the  yellow  granulations,  and  the 
yellow  bodies  mixed  with  the  pus  are  characteristic. 
The  diagnosis  should  always  be  confirmed  by  micro- 
scopic examination. 

295 


Differential  Diagnosis.  Actinomycosis  of  the 
cheek  may,  at  first  suggest  kipus;  but  when  the 
nodules  have  broken  through,  this  mistake  is  no 
longer  possible.  Extensive  infiltration  of  the  cheek 
may  be  mistaken  for  tumors,  especially  when  the  jaw 
and  the  tongue  are  also  afl^ected;  but  the  history  of 
the  formation  of  a  cord  extending  often  from  a 
carious  tooth,  followed  by  swelling  of  the  cheek  will 
lead  to  the  diagnosis.  Actinomycosis  of  the  tongue 
is  distinguished  from  abscess  or  gumma  by  extending 
to  the  base  of  the  tongue  and  causing  immobility; 
also,  in  actinomycotic  abscess  the  pus  contains  the 
characteristic  yellow  bodies.  Actinomycosis  of  the 
neck  may  be  mistaken  for  "wooden  phlegmon,"  but 
the  latter  is  generally  unilateral  and  uniform,  and 
does  not  form  fistulas;  actinomycotic  infiltration 
extends  round  the  whole  neck,  at  first  as  a  narrow 
zone,  later  on  as  several  zones  in  the  form  of  terraces 
one  above  another;  the  infiltration  is  also  irregular. 
Actinomycosis  of  the  lungs  and  pleura  may  be  mis- 
taken for  tuberculosis,  but  the  more  advanced  cases 
with  fistulas  are  unmistakable.  Actinomycosis  of 
the  intestine  may  be  mistaken  for  tuberculosis  or 
malignant  growths,  especially  when  it  forms  a  tumor- 
like mass  in  the  ileo-caecal  region. 

Treatment.  In  extensive  cases  of  antinomycosis 
of  the  buccal  cavity  attempts  at  total  extirpation  are 
useless,  but  healing  may  take  place  after  free  incision 
of  abscesses  and  laying  open  all  fistulas.  Granula- 
tion tissue  must  be  scraped  away,  and  indurated  tis- 
sue removed  as  far  as  possible.  The  incisions  should 
be  kept  open  for  a  long  time  by  tampons.  Carious 
teeth  must  be  removed.  In  actinomycosis  of  the 
lung  extensive  resection  of  ribs  is  often  necessary. 
In  actinomycosis  of  the  ileo-csecal  region  resection 
of  the  gut  may  be  necessary  on  account  of  intestinal 
obstruction  or  fistula.  In  other  cases  intestinal  acti- 
nomycosis comes  to  the  surface  and  then  only  requires 

296 


Bockenlieiiiicr.  Atlas. 


Tab.  XCIII. 


Fiy.  116.    yXktinomykosis  progressiva. 


Pplnlinn     r\>.n.i'...i>       M..»^.V..rl/ 


free  incisions.  Metastatic  deposits  in  the  bones 
(which  can  be  detected  by  the  X-rays)  may  require 
resection.  General  treatment  consists  in  nourishins: 
diet  and  the  administration  of  iodide  of  potassium 
and  arsenic. 

Fig.  115  shows  a  case  of  actinomycosis  of  the  cheek 
in  an  old  countrywoman.  Infection  took  place  from 
a  carious  molar  tooth.  A  cord-like  growth  extended 
from  the  root  of  the  tooth  to  the  gum,  and  thence  to 
the  mucous  membrane  and  muscles  of  the  cheek,  giv- 
ing rise  to  diffuse  infiltration.  The  skin  became 
bluish  red  and  several  small  fistulas  developed  which 
discharged  pus  containing  yellow  bodies.  The  latter 
were  found  by  microscopical  examination  to  be  acti- 
nomyces.  A  circumscribed  patch  of  gangrene  was 
caused  over  the  malar  bone  by  pressure  of  the  infil- 
tration. There  was  no  fever  and  little  trouble  except 
a  slight  degree  of  trismus.  Treatment  by  free  inci- 
sion and  plugging. 

Fig.  116  shows  a  case  of  extensive  actinomycosis  of 
the  neck  in  a  young  countryman.  The  point  of  infec- 
tion was  not  ascertained,  and  no  changes  w  ere  present 
in  the  mouth  or  pharynx.  Hard,  painless  infiltration 
extended  from  one  angle  of  the  jaw  to  the  other, 
finally  spreading  over  the  whole  region  of  the  neck. 
The  skin  was  at  first  unaltered,  but  afterwards 
became  dark  red.  A  circumscribed  abscess  formed 
in  the  submaxillary  region,  which  discharged  pus 
mixed  with  yellow  bodies  through  several  fistulas, 
with  yellow  granulation  tissue  at  their  orifices.  Both 
actinomyces  and  cocci  were  found  in  the  pus,  show- 
ing it  to  be  a  case  of  mixed  infection. 

The  patient  suffered  from  difficulty  in  breathing 
and  in  sw^allowing.  Free  incisions  were  made  in  the 
infiltration,  the  abscess  was  evacuated  and  the  fis- 
tulas scraped. 


297 


LINGUA  GEOGRAPHICA 

{Marginate  Glossitis — Geographical  Tongue) 
Plate  XCIV,  Fig.  117. 

This  affection  is  chiefly  of  interest  on  account  of 
the  possibility  of  its  being  mistaken  for  other  afi'ec- 
tions  of  the  tongue.  The  dorsal  surface  of  the  tongue 
is  covered  with  segments  of  circles  of  a  gray  color, 
arranged  irregularly  and  of  various  sizes.  The  inter- 
section of  these  segments  gives  rise  to  an  irregular 
polycyclic  or  "geographical"  pattern.  The  condi- 
tion is  caused  by  patches  of  hyperkeratosis  of  the 
filiform  papillae  which  spread  at  the  periphery  and 
become  normal  in  the  center.  The  peripheral  parts 
form  the  segments  of  circles  and  consist  of  an  accu- 
mulation of  desquamated  epithelium.  The  condition 
occurs  most  commonly  in  infants,  but  also  in  young 
adults.  It  runs  a  benign  course,  and  its  cause  is 
unknown.  It  has  been  attributed  to  a  syphilitic 
origin  by  Kaposi,  but  this  is  doubtful. 

Differential  Diagnosis.  Marginate  glossitis 
must  not  be  mistaken  for  leucoplakia.  The  two 
conditions  have  entirely  different  appearances.  (Cf. 
Fig.  9.) 

Treatment.  No  special  treatment  is  required 
beyond  mouth  washes,  painting  with  tincture  of 
myrrh  and  avoidance  of  spicy  foods. 

Fig.  117  shows  a  case  of  marginate  glossitis  affect- 
ing the  anterior  two -thirds  of  the  tongue.  The 
whole  tongue  is  divided  into  a  series  of  projecting 
areas  of  a  yellowish-white  color.  Between  these  areas 
are  the  gray  segments  filled  with  the  secretions  of  the 
mouth.  At  the  back  of  the  tongue  the  surface  is 
normal. 

298 


Bockcnheinier,  Atlas. 


Tab.  XC1\'. 


tr. 


tc 


zr. 


o 


U 


o 

o 


tjO 


M^w.Vrtrl/ 


Syphilis 

SCLEROSIS  SYPHILITICA  LINGUA 

(Syphilitic  Chancre  of  tongue) 

Plate  XCIV,  Fie;.'  118. 
GUMMA  LINGUJE— LINGUA  BIFIDA  (Gumma  of  tongue) 

Plate  XCIV,  Fig.  119. 
GUMMA  LABII  SUPERIORIS  ET  NASI 

(Gumma  of  upper  lip  and  nose) 

Plate  XCV,  Fig.  120. 
ABSCESSUS  GUMMOSI  (Gummatous  Abscess) 

Plate  XCV,  Fig.  121. 
OSTITIS   GUMMOSA  (Gummatotis  Osteitis) 

Plate  XCVI,  Fig.  122. 
ULCUS   GUMMOSUM  (Gummatous  Ulcer) 

Plate  XCMI,  Fig.  123. 

Syphilis  is  a  specific  infectious  disease  which,  in 
the  great  majority  of  cases,  is  contracted  by  sexual 
intercourse  between  human  beings.  It  is  probably 
caused  by  the  sjnrochaeta  pallida,  which  was  discov- 
ered in  1905  by  Schaudinn  and  Hoffmann,  and  has 
since  been  found  in  all  the  products,  and  also  in  the 
blood,  in  both  acquired  and  hereditary  syphilis.  The 
spirochaeta  pallida  is  a  delicate,  thin  organism  with 
corkscrew-like  spirals,  only  visible  under  high  mag- 
nification. It  is  best  stained  by  Giemsa's  stain  or 
Levaditi's  silver  nitrate  method. 

Syphilitic  infection  takes  place  through  slight 
excoriations  or  fissures  of  the  skin  or  mucous  mem- 
brane. In  this  way  extragenital  infection  may  occur 
in  various  parts  of  the  body  (lips,  eyelids,  tongue, 
nipple,  fingers,  etc.).  Indirect  contagion  may  also 
be  caused  by  contaminated  towels,  linen,  drinking- 
glasses,  cigars,  tobacco-pipes,  shaving  brushes,  etc. 
Congenital   or  hereditary   syphilis   is   the   result   of 

299 


syphilis  in  one  or  both  of  the  parents.  This  often 
causes  abortions  or  stillbirths. 

In  acquired  syphilis,  after  an  incubation  period  of 
three  to  five  weeks,  a  circumscribed,  hard,  painless 
infiltration  of  the  skin  or  mucous  membrane  develops 
at  the  point  of  infection,  called  the  initial  sclerosis  or 
hard  chancre.  This  forms  a  flat  erosion  with  a 
smooth,  dark-red  surface,  regular  smooth  borders 
and  an  indurated  base.  The  chancre  forms  a  hard 
nodule  movable  over  the  subjacent  tissues.  In  geni- 
tal infection  it  occurs  on  the  prepuce,  glans  penis  and 
labia,  more  rarely  in  the  urethra;  in  extragenital 
infection  it  occurs  at  the  part  of  the  body  inoculated. 

In  about  ten  per  cent,  of  cases  the  chancre  is  not 
discovered,  but  in  the  genital  organs  of  women  it  is 
often  overlooked.  The  chancre  generally  heals  in  a 
few  weeks  (with  or  without  treatment)  and  leaves  a 
white  scar  which  usually  disappears  in  course  of 
time.  Suppuration  only  takes  place  when  the  chan- 
cre is  infected  by  pus  cocci.  Sometimes  the  chancre 
becomes  gangrenous  (phagedenic  chancre).  Mixed 
chancre  is  due  to  simultaneous  infection  with  syph- 
ilis and  soft  chancre;  in  these  cases  the  soft  chancre 
appears  first  and  becomes  indurated  later  on.  The 
induration  of  hard  chancre  is  due  to  round-celled 
infiltration  chiefly  arising  in  and  around  the  walls  of 
the  small  blood-vessels. 

The  diagnosis  of  chancre  is  usually  easy  when  it  is 
situated  in  the  genital  organs,  but  extragenital  chan- 
cres are  often  overlooked.  Chancre  of  the  fingers 
often  resembles  a  chronic  whitlow  or  paronychia 
(Figs.  93  and  98) ;  but  the  sore  has  hard  borders  and 
a  smooth  surface  and  the  acute  inflammatory  symp- 
toms of  whitlow  are  absent.  About  a  week  after  the 
appearance  of  the  chancre  the  regional  lymphatic 
glands  become  enlarged,  forming  hard,  painless, 
movable  swellings  (indolent  bubo).  In  chancre  of 
the  genitals  the  inguinal  glands  are  aft'ected;  in  extra- 
genital chancre  the  regional  glands  corresponding  to 

300 


the  part  infected.  Suppuration  may  occur  in  the 
glands  if  the  chancre  is  infected  with  pus  cocci. 

Secondary  symptoms  appear  after  a  second  incu- 
bation period  of  six  to  twelve  wrecks.  They  often 
begin  with  malaise,  headache  and  pains  in  the  joints, 
accompanied  by  a  rise  of  temperature.  A  rose-red 
macular  rash  (syphilitic  roseola)  develops  on  the 
abdomen  and  thorax.  Later  on  various  syphilitic 
eruptions  develop  (secondary  syphilides),  the  most 
common  of  which  is  an  eruption  of  flat,  rounded, 
reddish-brown  or  ham-colored  papules  situated  on 
the  trunk,  face  and  limbs.  On  the  forehead  these 
papules  form  the  so-called  "corona  veneris."  On 
the  genital  organs  and  around  the  anus  these  papules 
become  sodden  and  white,  and  are  known  as  condyl- 
omata lata,  which  are  liable  to  ulcerate.  In  some 
cases  pustular  eruptions  form,  and  in  severe  or  neg- 
lected cases  the  pustules  become  ulcers  covered  with 
limpet-shaped  crusts  (syphilitic  rupia).  Acneiform 
eruptions  are  common  on  the  scalp,  and  scaly  or 
psoriasiform  syphilides  on  the  palms  and  soles. 
Most  secondary  eruptions  disappear  without  leaving 
any  trace,  but  the  ulcerative  forms  (rupia)  leave  pig- 
mented scars,  which  later  on  become  white  in  the 
center.  Syphilitic  eruptions  are  characterized  by 
their  reddish-brown  or  ham  color,  their  polymor- 
phous tendency  and  the  absence  of  itching. 

The  mucous  membranes,  especially  of  the  mouth, 
are  affected  by  papular,  erosive  or  ulcerative  syph- 
ilides which  are  know^n  as  mucous  patches.  These 
develop  on  the  tonsils,  fauces,  tongue,  and  inside  the 
lips  and  cheeks,  in  the  form  of  grayish-white  patches 
or  streaks,  with  a  red  border.  Later  on  they  may 
become  eroded  or  ulcerated  in  their  central  parts, 
and  then  appear  as  red  erosions  with  a  gray  border. 
In  early  secondary  syphilis  the  tonsils  and  fauces  may 
be  acutely  swollen  (syphilitic  angina),  but  more  often 
there  is  dark-red  coloration  of  the  tonsils,  fauces  and 
soft  palate.     In  secondary  syphilis  there  is  often  loss 

301 


of  hair,  sometimes  due  to  acneiform  syphilides  of  the 
scalp,  but  more  often  appearing  without  any  apparent 
lesion.  The  nails  are  sometimes  affected  with 
onychia  or  paronychia. 

Secondary  syphilis  may  last  several  years,  and  is 
liable  to  recurrences.  The  most  contagious  lesions 
are  condylomata  and  mucous  patches,  even  more 
contagious  than  the  chancre. 

Tertiary  syphilis  occurs  in  about  twenty  per  cent, 
of  cases,  usually  before  the  fifth  year,  sometimes  later, 
even  up  to  the  thirtieth  year  after  infection.  The 
chief  causes  of  tertiary  syphilis,  apart  from  specially 
virulent  forms  of  the  virus,  are  absence  of  or  insuflS- 
cient  treatment,  and  abuse  of  alcohol. 

The  characteristic  feature  of  tertiary  sj-philis  is 
the  formation  of  circumscribed  or  diffuse  infiltrations 
called  gummaia.  The  gumma  is  formed  of  round 
cells,  epithelioid  cells  and  giant  cells,  and  contains 
blood-vessels  thickened  by  syphilitic  arteritis.  Ow- 
ing to  the  changes  in  these  vessels,  the  nutri- 
tion of  the  gumma  is  interfered  with  and  the 
central  parts  undergo  fatty  degeneration  or  caseation. 
A  mature  gumma  shows  on  section  three  zones — a 
central  zone  of  caseation,  a  middle  zone  of  round 
cells  and  an  outer  zone  of  fibrous  tissue.  Gummata 
may  cicatrize  by  the  formation  of  fibrous  tissue,  or 
they  may  suppurate  and  form  an  abscess.  If  the 
abscess  is  superficial,  it  breaks  through  the  skin  and 
gives  rise  to  a  gummatous  ulcer. 

It  must  be  borne  in  mind  that  the  secretion  from 
gummatous  ulcers  may  be  contagious.  (The  spiro- 
chaeta  pallida  has  been  found  in  gummata,  and  any 
lesion  containing  this  organism  is  contagious). 

Gummata  develop  in  the  skin  and  subcutaneous 
tissue  in  the  form  of  circumscribed  nodules.  The 
skin  becomes  reddened  and  may  suggest  a  furuncle, 
especially  in  the  ease  of  a  single  gumma.  When  the 
gumma  breaks  through  the  skin  the  resulting  gum- 
matous ulcer  is  characteristic.     The  borders  are  hard, 

302 


smooth,  not  undermined  but  circular  and  sharply  cut, 
as  if  punched  out;  the  surface  is  covered  by  a  tough, 
tenacious,  yellowish  deposit,  or  core.  In  the  skin 
several  gummata  usually  occur  close  together;  these 
break  down  in  some  places  and  heal  in  others,  thus 
giving  rise  to  an  irregular  or  serpiginous  appearance 
which  is  characteristic  of  tertiary  syphilitic  ulceration. 
Gummata  sometimes  occur  on  the  penis  and  may 
somewhat  resemble  chancres,  but  there  is  no  enlarge- 
ment of  the  lymphatic  glands  in  gummata.  Gum- 
matous ulcers  generally  emit  a  disagreeable  odor, 
especially  when  they  are  situated  in  the  pharynx  or 
nose  (ozaena). 

Gummata  of  the  skin  may  be  secondary  to  exten- 
sion from  gummata  in  the  muscles  or  bones.  On 
the  other  hand  gumma  of  the  skin  may  extend  to  the 
deeper  tissues.  Diffuse  gummatous  infiltration  of 
the  skin  and  subcutaneous  tissue  gives  rise  to  multiple 
fistulas  which  discharge  a  scanty  secretion.  Gum- 
mata may  cause  extensive  deformity  by  destruction  of 
tissue,  especially  in  the  face  (Fig.  VZO).  Gummata  of 
the  scalp  leave  deep,  smooth,  glistening  scars.  Gum- 
ma of  the  tongue  is  usually  situated  in  the  center,  and 
may  divide  the  tongue  into  two  parts  (Fig.  119). 
Gummata  and  gummatous  infiltration  often  affect 
the  soft  palate  and  pharynx,  giving  rise  to  considera- 
ble destruction  of  tissue  and  cicatricial  stenosis.  The 
larynx  is  also  often  affected.  Gummatous  infiltra- 
tion of  the  rectum  gives  rise  to  stricture. 

Gumma  of  the  bones  may  develop  in  the  perios- 
teum, cortex  or  medulla,  in  the  form  of  circumscribed 
growths  or  diffuse  infiltration.  Generally,  all  three 
parts  of  the  bone  are  affected  with  simultaneous  bone 
destruction  and  bone  proliferation,  causing  an  irregu- 
lar, corroded  appearance.  Gumma  of  bone  may 
undergo  fibrous  transformation,  or  may  suppurate 
and  cause  necrosis.  Necrosis  of  the  cranial  bones 
often  leaves  circular  cavities  to  which  the  smooth, 
glistening  skin  is  firmly  adherent. 

303 


The  nose  and  hard  palate  are  often  extensively 
destroyed  by  gummatous  infiltration,  suppuration 
and  necrosis.  The  sternum  and  clavicle  are  some- 
times affected.  In  extensive  disease  of  the  long  bones 
curvature  may  result,  especially  outward  curvature 
of  the  tibia  from  the  weight  of  the  body.  There  is 
also  brittleness  of  the  bones.  Examination  by  X- 
rays  shows  irregular  shadows  in  the  periosteal  region, 
while  the  cortex  and  medulla  cannot  be  distinguished 
from  one  another.  The  whole  bone  is  thickened  and 
irregular. 

Patients  often  complain  of  pain  in  the  bones  (osteo- 
copic  pains)  before  any  changes  are  visible.  Palpi- 
tation of  the  anterior  surface  of  the  tibia  often  reveals 
an  irregular,  uneven  surface.  The  ulna,  radius  and 
fibula  may  also  be  the  seat  of  syphilitic  osteitis. 

Serous  effusion  may  occur  in  the  joints  and  bursas 
in  the  course  of  syphilis.  Extensive  disease  of  the 
joints  may  also  arise  from  gummatous  infiltration  of 
the  perisynovial  tissue,  or  from  gummatous  osteitis 
of  the  articular  ends  of  the  bones.  If  a  gumma  of  the 
bone  breaks  into  the  joint,  suppurative  arthritis  gen- 
erally follows.  The  knee  joints  are  most  often 
affected  by  syphilitic  arthritis. 

Gummata  may  occur  in  the  muscles,  and  may  be 
mistaken  for  tumors.  They  usually  occur  in  the 
tongue,  calf  muscles  and  sterno-mastoid.  Gumma 
in  the  brain  gives  rise  to  symptoms  of  cerebral 
tumor.  Gummata  are  common  in  the  liver  and 
testicles,  and  may  occur  in  the  lungs,  heart  and 
other  organs. 

The  blood-vessels  are  affected  in  all  three  stages 
of  syphilis  (syphilitic  arteritis).  The  changes  affect 
both  the  inner  and  outer  coats  of  the  vessels  (endar- 
teritis and  periarteritis).  Extensive  proliferation 
of  the  intima  may  cause  complete  occlusion  of  the 
vessel;  this  occurs  especially  in  the  vessels  of  the 
brain  and  leads  to  foci  of  softening.  Syphilitic 
arteritis  of  the  aorta  and  other  large  arteries  causes 

304 


aneurism.  Syphilitic  arteritis  of  the  cerebral  arteries 
causes  cerebral  hemorrhage. 

Each  of  the  three  stages  of  syphilis  may  be  absent. 
The  chancre  is  undiscovered  in  ten  per  cent,  of  cases, 
and  may  sometimes  be  absent.  Tertiary  syphilis  is 
said  to  occur  in  only  twenty  per  cent,  of  cases;  at 
any  rate  it  is  frequently  absent.  The  secondary  stage 
may  also  be  absent  in  cases  of  severe  infection  in 
which  tertiary  lesions  appear  soon  after  infection 
(malignant  syphilis).  It  is  also  possible  that  some 
cases  of  syphilis  undergo  spontaneous  abortion  after 
the  chancre. 

In  some  cases  of  congenital  syphilis  the  symptoms 
do  not  appear  till  the  eighth  to  sixteenth  year.  This 
is  known  as  late  or  delayed  hereditary  syphilis,  to 
distinguish  it  from  early  hereditary  syphilis  which 
appears  at  or  soon  after  birth. 

Among  the  characteristic  signs  of  early  hereditary 
syphilis  are  bullous  syphilides  of  the  palms  and 
soles  (syphilitic  pemphigus),  and  epiphysitis.  The 
latter  consists  in  a  form  of  osteochondritis  affecting 
the  epiphyses  of  the  long  bones,  and  causing  thick- 
ening. It  is  more  common  in  the  arm  and  gives  rise 
to  paralysis  of  the  limb.  Epiphysitis  may  cause 
interference  with  growth  of  the  limb. 

In  late  hereditary  syphilis  the  bones  are  frequently 
affected  with  gummatous  processes  identical  with 
those  of  acquired  syphilis.  The  tibias  are  often 
curved  forwards  and  outwards  owing  to  osteoplastic 
periostitis.  This  condition  is  known  as  "saber 
blade  tibia,"  and  is  a  characteristic  sign  of  late  hered- 
itary syphilis.  The  skin  over  the  bones  is  often 
ulcerated. 

Syphilitic  dactylitis  may  occur  in  both  early  and 
late  hereditary  syphilis.  It  causes  thickening  of  the 
phalanges,  usually  the  basal  ones.  It  is  generally 
multiple,  sometimes  bilateral,  and  tends  to  sponta- 
neous resolution  without  suppuration. 

The  bones  in  hereditary  syphilis  are  often  very 

305 


brittle.  Other  signs  of  hereditary  syphiHs  are  inter- 
stitial keratitis,  deafness  due  to  disease  of  the  internal 
ear,  notching  of  the  incisor  teeth  {Hutchinson's  teeth). 
These  three  signs  have  been  called  the  "Triad  of 
Hutchinson.'''  Radiating  scars  round  the  mouth  left 
by  former  ulcerations  are  also  characteristic. 

Acquired  syphilis  may  also  occur  in  infants,  but 
differs  in  the  absence  of  the  characteristic  features 
mentioned  above. 

Differential  Diagnosis.  Syphilis  is  so  wide- 
spread among  all  classes  of  society  that  it  must  always 
be  borne  in  mind  in  cases  of  doubtful  diagnosis. 
Although  the  disease  is  fairly  characteristic  in  all 
three  stages,  it  is  possible  to  mistake  it  for  other 
affections,  especially  as  the  history  can  never  be 
relied  upon. 

Hard  chancre,  when  ulcerated,  may  be  mistaken 
for  soft  chancre,  but  diagnosis  can  be  established  by 
finding  the  spirochaeta  pallida  in  scrapings.  Extra- 
genital chancres  may  be  mistaken  for  epithelioma, 
especially  in  the  tongue  and  nipple,  but  the  smooth 
surface  of  the  chancre  differs  from  the  irregular 
ulcerated  surface  of  epithelioma  (cf.  Fig.  1);  the 
regional  lymphatic  glands  are  affected  early  in  chan- 
cre. Chancre  of  the  fingers  is  often  mistaken  for 
whitlow,  but  difters  in  its  chronic  character  and 
absence  of  acute  inflammatory  symptoms.  Sec- 
ondary syphilis  of  the  skin  and  mucous  membranes 
may  be  mistaken  for  various  affections,  and  the 
diagnosis  often  depends  on  the  situation  and  general 
course  of  the  lesions,  and  on  the  presence  of  other 
signs  of  syphilis.  Gummatous  ulcerations  of  the 
skin  may  be  mistaken  for  tuberculous  ulcers  or  for 
furuncle,  but  differ  in  the  characters  mentioned 
above.  Diffuse  gummatous  infiltration  of  the  skin 
with  fungoid  proliferation  may  suggest  sarcoma  (cf. 
Figs.  24  and  26),  but  differs  in  the  absence  of  any 
tendency  to  bleeding,  in  the  presence  of  circular  scars 

306 


and  brown  pigmentation  in  the  surrounding  skin, 
and  in  the  presence  of  other  signs  of  syphiHs,  espe- 
cially changes  in  the  bones.  Gumma  in  a  muscle  is 
often  at  first  indistinguishable  from  a  tumor.  Gum- 
ma in  the  testicle  may  be  mistaken  for  tuberculosis, 
but  the  former  begins  in  the  testicle  while  tubercle 
begins  in  the  epididymis.  The  diagnosis  is  easy 
when  the  skin  of  the  scrotum  is  perforated. 

In  the  brain,  liver,  spleen  and  other  organs  the 
diagnosis  of  gumma  depends  on  other  signs  of 
syphilis.  Central  gumma  of  bone  may  resemble 
central  sarcoma  or  bone  cyst,  and  may  give  the  same 
appearance  on  X-ray  examination,  but  gummatous 
changes  in  bone  are  characterized  by  implication  of 
the  periosteum.  In  doubtful  cases  antisyphilitic 
treatment  should  be  tried.  If  the  diagnosis  hesitates 
between  gumma  and  malignant  tumor  antisyphilitic 
treatment  should  not  be  continued  too  long,  as  a 
malignant  tumor  may  thus  become  inoperable.  In 
such  cases  an  exploratory  incision  with  microscopical 
examination  is  to  be  preferred.  It  must,  however,  be 
borne  in  mind  that  long-standing  gumma  of  the  skin 
may  develop  into  carcinoma. 

The  earlier  the  diagnosis  and  the  sooner  the  com- 
mencement of  treatment,  the  quicker  is  the  cure  of 
syphilis.  On  the  w-hole  it  may  be  assumed  that  the 
majority  of  cases  become  cured,  but  the  marriage  of 
syphilitics  should  not  be  allowed  before  five  years 
after  infection,  and  then  only  after  thorough  and  pro- 
longed treatment,  with  an  additional  course  of  treat- 
ment shortly  before  marriage.  The  danger  of  trans- 
mission to  the  children  is  diminished  by  time  and 
treatment. 

The  disease  generally  runs  a  chronic  course,  and 
cases  of  acute  malignant  syphilis  are  rare  except  in 
persons  who  are  broken  down  in  health  from  other 
causes  (tuberculosis,  alcohol,  etc.).  In  the  tropics, 
however,  syphilis  is  more  severe  and  often  fatal.  It 
is  also  more  severe  in  races  who  are  attacked  for  the 

307 


jBrst  time  and  whose  ancestors  have  been  free  from 
the  disease. 

In  a  certain  number  of  cases  syphilis  causes  death 
by  gummatous  disease  of  the  internal  organs,  or  by 
diseases  of  the  nervous  system,  such  as  tabes  and 
general  paralysis,  which,  according  to  the  latest 
researches,  are  always  of  syphilitic  origin. 

[Reinfection  in  syphilis  is  rare,  but  may  sometimes 
occur  after  both  the  acquired  and  hereditary  disease. 
Immunity  in  hereditary  syphilis  does  not  appear  to 
last  much  beyond  the  age  of  puberty,  after  which 
acquired  syphilis  may  be  contracted,  usually  in  an 
attenuated  form.  No  doubt  a  soft  chancre  in  a 
syphilitic  subject  may  become  indurated  by  the 
syphilitic  process  and  be  mistaken  for  reinfection; 
so  may  a  chancriform  gumma  of  the  penis;  but  a 
considerable  number  of  cases  have  been  recorded  in 
which  patients  passed  through  two  distinct  attacks 
of  secondary  syphilis,  separated  by  an  interval  of 
several  years.  These  cases  must  of  course  be  dis- 
tinguished from  cases  of  relapsing  secondary  syphilis 
due  to  the  primary  infection. 

Treatment.  Infection  can  often  be  avoided  by 
cleanliness — by  using  ointment  before  coitus  and 
soap  and  water  afterwards.  Any  abrasion  of  the 
epithelium  of  the  penis,  caused  by  balanitis,  etc.,  may 
lead  to  infection.  Antisyphilitic  treatment  should  be 
commenced  as  soon  as  primary  syphilis  is  diagnosed; 
it  should  only  be  delayed  till  secondary  symptoms 
appear  in  cases  of  doubtful  chancre.  Excision  of  the 
chancre  has  been  often  tried,  but  it  cannot  prevent 
constitutional  infection  which  is  already  present; 
moreover,  an  ulceration  may  occur  at  the  place  of 
excision.  The  chancre  must  be  kept  clean  and 
dressed  with  iodoform,  xeroform  or  mercurial  oint- 
ment. Phagedenic  chancre  should  be  treated  by 
prolonged  immersion  in  mild  antiseptic  baths. 

Treatment  by  mercurial  inunction  is  one  of  the 

308 


best  methods,  and  can  be  carried  out  by  the  patient 
himself.  From  three  to  five  grammes  (about  a 
drachm)  of  unguentum  cinereum  is  rubbed  into  the 
skin  for  about  twenty  minutes  daily,  varying  the  seat 
of  inunction  from  day  to  day  (inner  side  of  arms  and 
thighs  and  sides  of  body).  This  is  best  done  at  night, 
the  patient  sleeping  in  a  flannel  nightshirt  and  taking 
a  hot  bath  in  the  morning.  On  the  seventh  day  the 
patient  omits  the  inunction.  The  whole  course  lasts 
six  weeks.  In  the  first  year  two  energetic  courses  of 
inunction  should  be  taken;  in  the  second  year  two 
milder  courses;    and  in  the  third  year  one  course. 

Treatment  by  intramuscular  injections  may  be 
employed  instead  of  inunction.  For  instance,  injec- 
tions of  one  cubic  centimeter  of  a  two  to  five  per 
cent,  solution  of  perchloride  of  mercury  with  sodiun 
chloride  every  two  or  three  days.  [Injections  of 
perchloride  of  mercury  are  painful  and  have  been 
replaced  by  other  preparations  of  mercury,  those 
most  generally  used  being  the  biniodide  and  gray  oil. 
Biniodide  is  a  soluble  injection  given  in  daily  injec- 
tions of  one-third  grain.  Gray  oil  is  a  preparation 
of  metallic  mercury  suspended  in  liquid  paraffin  and 
lanolin,  and  is  given  in  weekly  injections  of  one  to 
one  and  one-half  grains.  Injections  are  usually 
made  in  the  gluteal  muscles,  but  some  inject  into  the 
subcutaneous  tissue  of  the  back.  The  treatment  of 
average  cases  of  syphilis  can  also  be  carried  out  per- 
fectly well  by  internal  medication  in  the  form  of 
pills — blue  pill,  proto-iodide,  etc.] 

Erosions  and  ulcerated  mucous  patches  in  the 
mouth  may  be  painted  with  chromic  acid  (five  to 
ten  per  cent.).  To  avoid  mercurial  stomatitis  the 
teeth  should  be  cleansed  with  carbolic  tooth  powder, 
and  chlorate  of  potash  mouth  washes  used. 

In  the  tertiary  stage  iodide  of  potassium  is  indi- 
cated for  the  treatment  of  gummatous  formations 
(thirty  to  sixty  grains  daily).  It  may  be  given  in 
milk.     If  iodism  occurs  the  drug  should  be  discon- 

309 


tinued,  and  fifteen  to  thirty  grains  of  antipyrin  given 
daily  (Jadassohn).  If  iodide  cannot  be  borne, 
Zittmanns  decoction  may  be  tried.  Hot  baths  and 
vapor  baths  are  useful  in  improving  metabolism,  and 
favor  the  elimination  of  large  doses  of  mercury. 

Gummatous  ulcers  may  be  treated  with  iodoform, 
calomel  ointment,  or  gray  ointment.  Gummatous 
abscesses  may  be  incised  and  scraped.  Deformities 
of  the  lips,  nose,  etc.,  caused  by  gummata  recjuire 
plastic  operations.  Extensive  stricture  of  the  rectum 
may  necessitate  resection  of  the  gut.  Cases  of  cere- 
bral gumma,  which  do  not  yield  to  energetic  treat- 
ment with  mercurial  inunction  or  injection  and  large 
doses  of  iodide  of  potassium,  may  be  treated  by  tre- 
phining, when  they  cause  symptoms  of  a  circum- 
scribed cerebral  tumor.  Extensive  gummatous  dis- 
ease of  the  testicle  may  require  castration.  Gum- 
mata in  muscles  may  be  incised,  scraped  and  treated 
locally  with  mercurial  ointment,  if  they  do  not  yield 
to  general  antisyphilitic  treatment.  The  same  applies 
to  gummata  in  the  bones,  especially  when  they  cause 
severe  pain.  Gummatous  periostitis  and  osteitis 
often  heal  under  energetic  antisyphilitic  treatment, 
but  sometimes  require  operative  treatment  for  the 
removal  of  sequestra.  In  cases  of  delayed  union  of 
fractures,  iodide  of  potassium  is  often  useful  when 
there  is  a  history  of  previous  syphilis.  The  same 
applies  to  all  badly  healing  wounds  in  syphilitic 
patients,  especially  operation  wounds.  In  hereditary 
syphilis,  osteochondritis  can  be  treated  by  splints, 
and  gummatous  osteitis  may  eventually  require 
operative  interference.* 

*  For  further  information  on  this  subject  the  reader  is  referred  to 
Marshall's  "Syphilology  and  Venereal  Disease,"  London.  Bailiere, 
Tindall  and  Cox;  Marshall's  "Golden  Rules  of  Venereal  Disease," 
Bristol.  John  Wright  and  Co. :  Marshall's  translation  of  Foiirnier's 
"Treatment  and  Prophylaxis  of  Syphilis,"  New  York.     Rebman  Co. 


310 


SCLEROSIS  SYPHILITICA  LINGUA 

(Si/phililic  chancre  of  the  tongue) 
Plate  XCIV,  Fig.  118. 

This  is  a  case  of  extragenital  chancre  affecting  the 
tongue.  The  sore  is  sHghtly  raised  above  the  sur- 
face; it  has  a  round  form  with  hard,  sHghtly  raised 
not  undermined  borders,  and  a  smooth,  varnished 
surface.  The  lymphatic  glands  in  the  submaxillary 
and  occipital  regions  were  hard  and  movable.  Car- 
cinoma of  the  tongue  differs  from  this  in  its  irregular 
surface,  from  which  epithelial  plugs  can  be  expressed, 
and  in  the  glandular  affection  occurring  later. 

As  already  mentioned,  syphilitic  contagion  may 
take  place  through  intermediate  objects.  Vo7i  Berg- 
mann  has  observed  a  case  in  which  contagion  was 
due  to  smoking  the  fag  end  of  a  cigarette  thrown 
away  by  a  syphilitic  person. 


311 


GUMMA  LmCUiE— LINGUA  BIFIDA   {Gumma  of  the  tongue) 
Plate  XCIV,  Fig.  119. 

Gumma  of  the  tongue  is  usually  situated  in  the 
center  of  the  tongue,  while  carcinoma  generally 
affects  the  posterior  part  of  the  side  of  the  tongue 
(Fig.  9).  A  breaking-down  gumma  may  divide  the 
tongue  into  two  parts  (bifid  tongue).  The  figure 
shows  a  broken-down  gumma  with  its  characteristic 
tenacious,  yellowish-brown  deposit.  Syphilitic  infec- 
tion was  denied  in  this  case,  but  it  was  cured  by 
antisyphilitic  treatment. 


312 


Hockenheinicr,  Atlas. 


Tab.  XCV. 


O 
S 
S 


ID 
O 
en 
Xi 

< 


o 
5 


r3 


O 

n 


Rcbman  Company,  New- York. 


GUMMA  LABII  SUPERIORIS  ET  NASI 

{Gumma  of  the  upper  lip  and  nose) 
Plate  XCV,  Fig.  liO. 

This  case  shows  extensive  destruction  of  the  upper 
lip,  the  cartilaginous  portion  of  the  nose,  the  nasal 
septum,  and  the  bony  framework  of  the  nose,  due  to 
gummatous  ulceration.  There  is  also  perforation  of 
the  hard  palate.  The  upper  lip  shows  the  character- 
istic yellow,  tenacious  deposit,  which  can  be  removed 
without  bleeding.  The  surface  of  the  ulceration  is 
fairly  smooth  and  the  borders  soft,  as  compared  with 
the  irregular  surface  and  hard  borders  of  carcino- 
matous ulceration.  The  patient  had  syphilis  ten 
years  previously. 

The  patient  was  treated  with  iodide  internally  and 
mercurial  ointment  locally.  After  the  ulcerated  sur- 
face had  become  clean,  the  borders  were  excised  and 
united  by  sutures.  The  defect  in  the  nose  was 
repaired  by  a  plastic  operation,  and  an  obturator 
was  worn  for  the  perforation  in  the  palate. 


313 


ABSCESSUS  GUMMOSI  (Gummatous  Abscess) 
Plate  XCV,  Fig.  121. 

This  is  a  case  of  multiple  gummata  in  the  skin  of 
the  face,  situated  at  the  root  of  the  nose,  in  the  left 
eyelid  and  in  the  temporal  region.  The  skin  is  thin 
and  red.  Fluctuation  was  felt  on  palpation.  The 
patient  could  not  remember  contracting  sj-philis,  but 
his  wife  had  had  frequent  abortions  and  several 
syphilitic  children.  There  were  gummatous  pro- 
cesses in  the  skin  of  various  parts  of  the  body;  also 
limitation  of  movement  in  the  elbow  joint  due  to 
previous  gumma  of  the  bone.  The  surface  of  both 
tibias  was  irregular,  and  there  were  circular  scars 
on  the  legs.  The  patient  also  suffered  from  severe 
headache  and  attacks  of  giddiness,  due  to  syphilitic 
disease  of  the  cerebral  arteries. 

The  abscesses  were  incised  and  scraped,  and 
healed  under  antisyphilitic  treatment.  The  cerebral 
symptoms  also  improved. 


314 


Bockeniieimer,  Atlas. 


Tab.  XC\'I 


trq 


to 
to 


C 


5 


Q 


Kcbinan  Company,  Ne«-\'aik. 


OSTITIS  GUMMOSA  (Gvmmatous  OsteUis) 
Plate  XC\'I,  Fig.  1>22. 

This  patient  acquired  sypiiiiis  twenty  years  ago, 
and  suffered  for  some  years  from  pain  in  the  right 
forearm,  especially  at  night.  The  bones  of  the  fore- 
arm gradually  became  thickened,  and  the  skin  red 
and  swollen.  Two  irregular  ulcers  developed,  cov- 
ered with  yellow,  tenacious  deposit.  Round  the 
ulcers  soft  proliferations  formed  resembling  sarcoma- 
tous tissue.  There  were  several  small  fistulas  lead- 
ing to  the  bones,  in  which  the  X-rays  showed  irregular 
proliferation  of  the  periosteum  and  irregular  thick- 
ening of  the  cortex.  Healing  gradually  took  place 
under  treatment  by  iodide  internally  and  mercurial 
ointment  locally.  There  were  no  other  signs  of 
syphilis. 


315 


ULCUS  GUMMOSUM    {Gummatous  Ulcer) 
Plate  XCVII.  Fig.  123. 

In  this  case  a  gumma  occurred  in  the  skin  over  the 
internal  malleolus  after  a  kick  (trauma  is  sometimes 
an  exciting  cause  of  gumma).  The  skin  became 
infiltrated,  swollen  and  red,  and  gradually  broke 
down,  forming  an  ulcer  with  sharply  cut  edges  and 
a  base  covered  with  tenacious,  yellow  deposit.  The 
patient  contracted  a  sore  on  the  penis  some  years 
previously,  which  was  diagnosed  as  a  soft  chancre, 
and  received  no  specific  treatment.  Three  years 
after  infection  a  gumma  developed  in  this  situation 
and  was  treated  for  a  long  time  with  poultices,  but 
was  afterwards  healed  by  iodide  of  potassium  inter- 
nally and  mercurial  ointment  locally.  The  patient 
was  recommended  further  treatment  by  mercurial 
inunction  or  injections. 


316 


Bockenheimer,  Atlas. 


Tab.  XCVII. 


■n 

D 


CO 


Rebman  Company.  New-York 


Tuberculosis 


LYMPHOMATA  COLLI  TUBERCULOSA 

(Ti/hrrciiloiix  lymphoma  of  the  Neck) 
Plate  XCVIII.  Fig.  134. 
ARTHRITIS  TUBERCULOSA  FUNGOSA 

(Fungaling  Tuberculouji  Arthritu) 
ANKYLOSIS  GENUS  FIBROSA 
ABSCESSUS  FRIGIDUS 

(Fibrous  Anchylosis  of  the  Knee — Cold  Abscess) 
Plate  XCIX,  Fig.  125. 
ARTHRITIS  TUBERCULOSA  PURULENTA 

(Purulent  Tuberculous  Arthritis) 
Plate  C,  Fig.  126. 
ARTHRITIS  TUBERCULOSA  FIBROSA 

(Fibrous  Tuberculous  Arthritis) 
ANKYLOSIS  OSSEA— SUBLAXATIO 

(Bonij  Anchylosis — Subluxation) 
Plate  C,  Fig.  127. 
ARTHRITIS  TUBERCULOSA    FIBROSA 

(Fibrous  Tuberculous  Arthritis) 
TUMOR    ALBUS    (nidtc  swelling) 

Plate  CI,  Fig.  128. 
TUBERCULOSIS  TESTIS    (Tuberculous  Testicle) 

Plate  CII,  Fig.  129. 
TUBERCULOSIS   MANUS  (Tuberculosis  of  the  Hand) 

Plate  cm.  Fig.  130. 
OSTITIS  TUBERCULOSA  (Tuberculous  Osteitis) 
SPINA  VENTOSA   (Spina  reniosa) 

Plate  CIV,  Fig.  131. 
GANGRjENA  PEDIS  HUMIDA  (Moist  Gangrene  of  the  Foot) 
Plate  CIV,  Fig.  132. 

Since  the  discovery  of  the  tubercle  baciUus  by 
Robert  Koch,  in  1881,  it  is  known  that  tuberculous 
affections  are  solelv  due  to  the  invasion  of  these 
bacilli;  although  tuberculosis  was  regarded  as  an 
infective  disease  by  several  investigators  before 
the  time  of  Koch.  Baumgarten  also  discovered  the 
tubercle  bacillus  almost  at  the  same  time  as  Koch. 

317 


The  tubercle  bacilli  are  straight  or  slightly  curved 
rods.  They  are  easily  stained  by  the  Ziehl-N eelsen 
method,  or  by  Gram's  method,  and  are  not  decolor- 
ized by  nitric  acid  solution  (acid  fast  bacilli).  The 
bacilli  retain  their  virulence  for  a  long  time  in  the 
dry  state,  but  are  destroyed  by  boiling  and  by  sun- 
light. Besides  microscopic  examination  and  culture 
oi  the  bacilli,  inoculation  of  the  guinea  pig  is  useful 
for  establishing  diagnosis.  Recent  researches  by 
Friedrich  have  shown  that  tubercle  bacilli  in  cultures 
assume  the  form  of  club-shaped  radiating  filaments 
similar  to  actinomyces;  so  that  the  bacillary  nature 
of  the  tubercle  bacillus  is  doubtful,  and  it  may  belong 
to  the  hvphomycetes.  In  any  case  tuberculosis  and 
actinomycotic  affections  are  often  very  similar. 

Tubercle  bacilli  are  present  in  dust  and  on  the 
walls  of  rooms.  Patients  with  tuberculosis  of  the 
lunsrs  infect  the  air  with  small  vesicles  of  fluid  con- 
taining  tubercle  bacilli.  Tubercle  bacilli  may  also 
penetrate  the  unbroken  skin  and  mucous  membrane 
and  cause  infection  of  the  lymphatic  glands;  but  this 
form  of  infection  is  comparatively  rare.  Wounds  are 
easily  infected  with  tubercle  bacilli,  especially  when 
the  sputum  of  a  tuberculous  subject  comes  in  con- 
tact with  a  wound  {e.g.  tattooing).  Although,  accord- 
ing to  Koch,  there  may  be  a  distinction  between 
human  and  bovine  tuberculosis,  the  latter  may  be 
transmitted  to  man,  and  infection  may  occur  from 
the  meat  and  milk  of  animals  infected  with  bovine 
tuberculosis;  [especially  by  milk  from  cows  with 
tuberculous  udders]. 

As  regards  the  hereditary  transmission  of  tuber- 
culosis, it  is  certain  that  the  children  of  tuberculous 
parents  are  more  predisposed  to  tuberculosis  than 
the  children  of  healthy  parents;  but.  whether  the 
bacilli  can  be  transmitted  from  the  mother  to  the 
fetus  and  remain  for  a  long  time  latent  in  the  tissues 
of  the  child,  and  whether  transmission  can  take  place 
through  the  semen  of  the  father,  are  points  which  are 

318 


still  unsettled.  In  distinction  to  hereditary  predis- 
position, there  is  acquired  predisposition;  after  cer- 
tain diseases,  such  as  influenza,  measles,  bronchial 
catarrh  and  glandular  swellings.  The  stronger  the 
body  at  the  time  of  infection,  the  more  it  is  able  to 
resist  the  disease.  It  is  said  that  signs  of  former 
tuberculosis  can  be  found  in  almost  ninety  per  cent, 
of  all  men,  in  a  great  many  of  these  cases  the 
tuberculous  foci  having  become  encapsuled  or  cal- 
cified. Bad  feeding,  unhealthy  dwellings,  sedentary 
occupations  and  alcoholism  predispose  to  infection. 

In  the  great  majority  of  cases  primary  tuberculosis 
affects  the  lungs,  either  by  direct  inhalation  of  bacilli, 
or  by  bacillary  infection  of  the  lymphatic  glands 
(tonsils,  bronchial  glands,  nasopharyngeal  glands). 
If  the  bacilli  remain  in  the  lungs  they  give  rise 
to  phthisis.  Tuberculosis  of  the  mouth,  pharynx, 
larynx,  trachea,  bones  and  all  other  tissues,  is  in 
most  cases  due  to  secondary  metastatic  infection  by 
the  blood.  Tuberculous  embolism  may  be  caused 
by  a  tuberculous  focus  breaking  through  a  large 
vessel. 

Tuberculous  lesions  which  interest  the  surgeon  are 
in  the  majority  of  cases  secondary.  Tuberculosis 
may  attack  any  of  the  tissues,  but  has  a  predilection 
for  certain  ones — primary  tuberculosis  for  the  lymph- 
atic glands  and  lungs;  secondary  tuberculosis  for 
the  bones  and  joints.  Tuberculosis  of  the  intes- 
tine, which  generally  affects  the  small  intestine  and 
ileocaecal  region,  is  rarely  primary  but  generally 
secondary  to  tuberculosis  of  the  lung  (by  swallowing 
phthisical  sputum)  or  the  mesenteric  glands.  Tuber- 
culosis may  occur  at  any  age. 

The  tubercle  bacilli  give  rise  to  small  nodular 
infiltrations  known  as  tubercles  or  granulomas.  The 
granuloma  is  characterized  by  the  presence  of  several 
forms  of  cells,  the  majority  of  which  are  round  cells, 
a  smaller  number  epithelioid  cells,  in  fresh  tubercles; 
while    in    older    tubercles    giant    cells    are    present, 

319 


especially  in  tubercles  with  a  tendency  to  heal.  The 
giant  cells  of  tubercle  differ  from  other  giant  cells  in 
the  fact  that  the  nuclei  are  situated  at  the  periphery 
of  the  cell  round  a  central  homogeneous  mass,  and 
that  in  some  parts  of  the  circumference  of  the  cell 
there  is  a  double  arrangement  of  nuclei.  Owing  to 
the  absence  of  blood-vessels  in  the  center  of  the  tuber- 
cle there  is  caseous  degeneration  of  the  central  cells. 
The  giant  cells  often  contain  tubercle  bacilli  and  are 
believed  to  take  part  in  the  process  of  healing,  by 
acting  as  phagocytes. 

The  tubercle  sets  up  inflammatory  reaction  in  the 
surrounding  tissues,  resulting  in  the  formation  of 
granulation  tissue  and  pus,  the  latter  being  discharged 
by  a  fistula,  or  forming  an  ulcer  when  the  process  is 
in  the  skin.  In  most  cases  the  body  tries  to  expel 
the  tuberculous  focus,  but  in  some  cases  the  latter 
becomes  encapsuled  by  connective  tissue.  This  con- 
nective-tissue capsule  may  at  any  time  be  ruptured, 
by  trauma,  etc.,  and  give  rise  to  fresh  tuberculous 
infection.  The  majority  of  cases  of  tuberculosis  fol- 
lowing an  injury  are  explained  by  the  setting  free  of 
encapsuled  foci  of  tubercle;  this  not  only  causes  a 
fresh  outbreak  of  tubercle  at  the  seat  of  the  injury, 
but  also  spread  of  the  previously  encapsuled  focus  of 
disease  to  other  organs. 

Surgical  cases  of  tuberculosis  are  generally  charac- 
terized by  the  formation  of  typical  granulations,  fis- 
tulas and  specific  pus.  The  granulations  are  pale 
and  vitreous.  The  fistulas  run  an  irregular  course, 
and,  in  cases  of  tuberculous  bone  disease,  open  at 
more  or  less  distant  points  in  the  skin;  the  walls  of 
the  fistula  are  soft  and  bleed  easily.  The  pus  is  thin 
and  mixed  with  fibrin,  caseous  masses  and  shreds  of 
tissue.  The  tuberculous  ulcer  is  characterized  by 
thin,  soft,  ragged,  undermined  borders,  and  a  base 
covered  with  yellow  caseous  masses,  or  pale-red  or 
gray  granulations.  Tuberculous  granulations  may 
destroy  all  the  surrounding  tissues  (bones,  cartilage 

320 


and  muscles)  and  the  necrosed  parts  are  expelled 
from  the  body.  In  the  majority  of  cases  there  is  a 
formation  of  soft,  spongy  granulations,  and  little 
fibrous  tissue  formation.  Tuberculous  processes 
often  continue  for  years  before  an  abscess  forms,  or 
a  cavity  from  destruction  of  the  tubercle. 

Tuberculosis  affects  the  different  tissues  in  char- 
acteristic ways,  which  we  shall  describe  later  when 
dealing'  with  the  different  cases.  As  a  rule  it  runs  a 
chronic  course  with  intermittent  fever,  without  acute 
inflammatory  symptoms.  The  diagnosis  can  often 
be  made  from  the  appearance  of  the  ulcer,  fistula, 
pus  or  granulation  tissue,  and  by  the  X-rays  in  the 
case  of  bone  disease.  In  many  cases  tuberculosis  of 
the  luns  leads  to  tuberculous  disease  of  other  tissues. 
Diagnosis  can  be  confirmed  by  microscopic  examina- 
tion; or  by  inoculation  of  suspected  tissue  into  the 
peritoneum  of  the  guinea-pig,  which  gives  rise  to 
tuberculosis  of  the  mesenteric  glands  in  a  few  weeks. 
The  walls  of  tuberculous  abscesses  are  very  suitable 
for  inoculation,  as  they  contain  many  tubercle  bacilli. 

The  prognosis  depends  on  the  situation  and  extent 
of  the  disease.  Small,  circumscribed  foci  can  be 
radically  removed  by  operation — for  instance,  cir- 
cumscribed tuberculosis  of  the  skin,  or  tuberculous 
jrlands  in  the  neck  which  are  common  in  children. 
However,  as  tubercle  is  generally  present  in  the  lungs, 
many  patients  succumb  to  this  sooner  or  later.  In 
tuberculosis  of  bones  and  joints,  complete  restitution 
is  seldom  possible,  owing  to  the  extensive  destruction 
of  tissue.  Long-standing  disease  of  bones  and  joints, 
which  may  occur  at  an  advanced  age,  is  often  fatal 
from  exacerbation  of  tuberculosis  of  the  lungs. 

Treatment.  The  spread  of  the  disease  should  be 
checked  by  prophylactic  measures.  Tuberculous 
patients  should  be  warned  against  spitting  into  hand- 
kerchiefs or  on  the  ground,  and  should  use  spitting- 
cups.     Meat  and  milk  from  tuberculous  cattle  should 

321 


not  be  consumed.  The  general  treatment  of  tuber- 
culous patients  consists  in  nourishing  diet  (plenty  of 
milk,  meat  and  butter),  cod-liver  oil  and  extract  of 
malt;  administration  of  preparations  such  as  creo- 
sote and  guiacol;  residence  at  high  altitudes;  sea 
baths;  sanatorium  treatment.  Inunction  of  the 
whole  body  with  green  soap,  which  is  allowed  to 
remain  on  the  skin  for  half  an  hour,  is  said  to  be 
beneficial.  Brine  baths  and  sulphur  baths  are  useful. 
Tuberculin  treatment  has  not  been  successful,  and 
cannot  be  recommended  in  practice.* 

As  regards  local  treatment,  the  object  of  modern 
surgery  is  to  remove  the  focus  of  disease  when  it  is 
within  reach.  By  this  means  not  only  is  the  local 
disease  often  cured,  but  the  primary  lung  disease  is 
often  improved.  In  some  cases  a  whole  organ,  such 
as  the  kidney  or  testicle,  must  be  removed  when  it  is 
extensively  diseased.  A  ten  per  cent,  emulsion  of 
iodoform  in  glycerin  is  useful  for  application  to 
tuberculous  ulcers  and  fistulas,  and  for  injection  into 
tuberculous  joints  and  abscesses.  In  the  treatment 
of  tuberculous  bone  and  joint  disease  immobilization 
is  essential. 

Tuberculosis  of  the  Skin.  This  has  already 
been  mentioned  in  the  case  of  lupus.  (Plate  III.) 
Local  tuberculosis  of  the  skin  may  occur  from  infec- 
tion from  dead  bodies  affected  with  tuberculosis. 
This  form  is  common  on  the  fingers  in  doctors  and 
hospital  attendants  after  post-mortem  examinations, 
and  in  butchers  from  handling  tuberculous  meat. 
It  is  known  as  cadaveric  tubercle  or  post-mortem 
wart.  It  commences  as  a  small  red  spot  which 
develops  into  a  raised  nodule  with  slight  sanious 
discharge.  Several  nodules  may  develop  close  to- 
gether and  form  a  warty  growth.     A  more  extensive 

*  Sir  Almroth  Wright's  method  by  injection  of  the  new  tubercuh'n, 
under  control  of  the  opsonic  index,  is  apparently  successful  in  suit- 
able cases. 

322 


form  of  warty  cutaneous  tuberculosis  is  known  as 
tuberculosis  verrucosa,  and  is  common  in  the  poorer 
classes.  In  these  cases  the  tubercles  have  little  ten- 
dency to  break  down  and  undergo  caseous  degenera- 
tion, but  become  warty  by  cornification  of  the  epi- 
dermis. 

The  treatment  of  these  forms  of  cutaneous  tuber- 
culosis is  the  same  as  for  lupus;  viz.  excision  of 
small  lesions;  scraping  with  sharp  spoon,  cauteriza- 
tion, or  treatment  by  Finsen's  light  in  the  case  of 
larger  growths. 

Another  form  of  cutaneous  tuberculosis  commences 
in  the  subcutaneous  tissue,  and  gradually  extends  to 
the  skin  in  the  form  of  red  nodules  resembling  fur- 
unculous  abscesses.  The  skin  becomes  thin,  the 
nodules  suppurate  and  discharge  pus  on  the  surface. 
This  condition  is  common  in  the  neck  in  tuberculous 
children.  Before  the  skin  breaks  down  the  nodules 
may  be  mistaken  for  gummata,  but  afterwards  typical 
tuberculous  ulcers  are  formed.  This  condition  has 
been  called  scrofuloderma,  but  is  due  to  the  action 
of  tubercle  bacilli.  The  treatment  consists  in  scrap- 
ing and  iodoform  dressings. 

Tuberculous  Lymphangitis  and  Lymphade- 
nitis. Tuberculous  lymphangitis  is  rare,  and  only 
occurs  in  connection  with  tuberculosis  of  the  skin 
and  lymphatic  glands,  in  the  form  of  nodular  cords. 
Tuberculous  lymphadenitis,  on  the  other  hand,  is 
very  common  (Fig.  124).  It  occurs  especially  in 
children  in  the  glands  of  the  neck,  the  tubercle 
bacilli  easily  penetrating  the  soft  walls  of  the  lym- 
phatic vessels.  The  glands  may  be  affected  by  way 
of  the  blood  or  lymph,  after  eczema,  ulcers  or  tuber- 
culosis of  the  neighboring  tissues.  Through  slight 
lesions  of  the  mucous  membrane  of  the  mouth  or 
pharynx,  the  tubercle  bacilli  enter  the  lymphatics, 
and  infect  the  glands  of  the  neck  and  submaxillary 
region.     Some  authorities  maintain  that  tuberculosis 

323 


of  the  lunffs  is  secondarv  to  tuberculous  disease  of  the 
bronchial  glands,  and  intestinal  tuberculosis  to  dis- 
ease of  the  mesenteric  glands.  The  tubercle  bacilli 
cause  inflammatory  swelling,  and  the  formation  of 
miliary  tubercles  in  the  glands.  Several  miliary 
tubercles  become  confluent  and  form  larger  nodules 
which  undergo  caseous  degeneration  and  softening, 
and  finally  suppurate.  The  tuberculous  process 
is  not  usually  limited  to  a  single  gland,  but  extends 
through  the  capsule  to  the  surrounding  tissue, 
and  finally  to  the  skin.  The  glandular  tumor,  at 
first  circumscribed  and  covered  with  intact  skin,  soon 
implicates  the  skin  and  breaks  through  it  in  one  or 
more  places,  forming  fistulas  which  discharge  thin, 
greenish  pus.  The  pus  often  burrows  under  the 
skin  and  breaks  through  in  more  or  less  remote 
places.  The  axillary  and  inguinal  glands  are  seldom 
the  seat  of  primary  tuberculosis. 


Differential  Diagnosis.  Tuberculous  glands  are 
characterized  by  the  variation  in  their  consistence; 
some  glands  being  soft  and  fluctuating,  others  hard. 
In  the  absence  of  fistulas  or  other  signs  of  tubercu- 
losis, an  isolated  tuberculous  gland  may  be  mistaken 
for  a  suppurating  sebaceous  cyst  or  dermoid.  The 
differential  diagnosis  from  malignant  tumors  has 
already  been  described  (Fig.  24).  In  doubtful  cases 
microscopic  examination,  or  inoculation  in  the  guinea 
pig  will  establish  the  diagnosis. 


Treatment.  The  primary  cause  (eczema,  ulcers, 
etc.),  must,  of  course,  be  treated.  Circumscribed 
glandular  abscesses  may  be  evacuated  by  puncture 
and  injected  with  ten  per  cent,  iodoform  emulsion. 
Larger  groups  of  glands  should  be  freely  laid  open 
and  removed.  Removal  of  tuberculous  glands  in 
the  neck  requires  an  accurate  knowledge  of  anatomy, 
as  these  glands  are  often  situated  around  the  large 

324 


vessels  from  the  mastoid  process  to  the  suprachivicii- 
hir  fossa,  and  lie  behind  the  sterno-mastoid  muscle 
and  sometimes  under  the  trapezius.  After  extirpa- 
tion, the  wound  should  be  plugged  with  iodoform 
gauze  and  the  wound  closed,  leaving  a  small  space 
for  drainage.  In  children  especially,  there  is  a  rise 
of  temperature  for  the  first  few  days  after  extensive 
removal  of  glands,  which  is  probably  due  to  the 
entrance  of  tubercle  bacilli  into  the  blood.  Miliary 
tuberculosis  may  develop  after  extensive  removal  of 
tuberculous  glands.  It  is,  therefore,  better  in  exten- 
sive glandular  disease,  occurring  in  feeble  patients, 
to  limit  operative  interference  to  incision  and  scrap- 
ing- 
Tuberculous  lymphadenitis  of  the  neck,  especially 
when  associated  with  eczema  of  the  eyelids,  otitis 
media  and  ulcers  of  the  cornea,  is  often  wrongly 
called  scrofula.  Staphylococci  are  often  found  along 
with  tubercle  bacilli.  In  cases  where  no  tubercle 
bacilli  are  found  it  is  possible  that  they  have  been 
destroyed  by  the  pus  cocci.  The  term  scrofula 
should,  therefore,  be  avoided,  especially  when  typical 
tuberculous  disease  is  present  in  other  parts  of  the 
body.  Predisposing  causes  of  tuberculous  lympha- 
denitis are — measles,  influenza,  whooping-cough,  un- 
cleanliness  and  improper  feeding.  General  treat- 
ment consists  in  the  measures  already  mentioned, 
especially  sea  and  sulphur  baths. 

Tuberculosis  off  Bone.  Tuberculous  disease  of 
bones  is  secondary,  and  caused  by  the  spread  of 
tuberculous  material  by  way  of  the  blood.  For  this 
reason  the  bones  are  generally  aft'ected  in  certain 
places  corresponding  to  the  distribution  of  their 
blood-vessels.  Lexer  found,  by  X-ray  examination 
after  injection  of  the  vessels  of  bones  with  mercury, 
that  the  nutrient  artery  of  the  long  bones  terminated 
in  the  epiphyses.  This  explains  the  frequency  with 
which  the  epiphyses  of  the  long  bones  are  affected 

325 


with  tuberculous  deposits,  by  plugging  the  terminal 
branches  of  the  nutrient  artery  in  the  epiphysis  with 
tuberculous  infarcts.  In  the  short  bones  the  nutrient 
artery  terminates  soon  after  its  entrance  in  the  middle 
of  the  diaphysis;  hence  tuberculous  disease  of  these 
bones  affects  the  diaphysis.  Tuberculosis  also  affects 
the  vertebrae,  the  bones  of  the  hand  and  foot,  the 
cranial  bones,  the  sternum,  ribs  and  ilium. 

In  most  cases  there  is  circumscribed  disease  in  the 
form  of  a  caseous  sequestrum.  Around  this  form 
granulation  tissue  and  pus,  which  seeks  a  way  to  the 
surface  by  the  formation  of  a  fistula.  Small  sequestra 
often  give  rise  to  large  abscesses  which  become  visible 
under  the  skin,  often  at  some  distance;  these  are 
known  as  "cold  abscesses"  (Fig.  125).  Tuberculo- 
sis of  the  vertebrae  may  thus  cause  abscesses  which 
appear  in  the  thigh.  In  tuberculous  bone  disease 
there  is  little  tendency  to  the  formation  of  new  bone. 
In  some  cases  the  focus  of  disease  may  become  encap- 
suled  in  the  bone,  but  is  always  liable  to  recrudes- 
cence, especially  after  an  injury.  More  commonly 
the  sequestrum  is  discharged  piecemeal  through  a 
fistula,  thus  differing  from  the  large  sequestrum  of 
pyogenic  osteomyelitis.  Multiple  foci  of  disease  often 
occur  in  one  or  more  bones.  When  the  bone  is 
exposed  by  incision,  irregular,  caseous  fragments 
are  seen,  together  Avith  pus.  When  the  disease 
occurs  in  the  epiphyses  of  the  long  bones  it  may 
break  into  the  joint,  giving  rise  to  suppurative 
arthritis. 

Although  the  foci  of  disease  are  usually  small,  and 
there  is  seldom  the  necrosis  of  large  portions  of  bone 
which  occurs  in  pyogenic  osteomyelitis,  there  may  be 
extensive  disease  of  the  medullary  cavity  when 
tuberculous  disease  of  a  joint  extends  to  the  bones. 
The  phalanges  may  also  be  extensively  diseased. 
Sometimes  no  changes  are  found  in  the  bone,  and 
the  disease  is  confined  to  the  periosteum,  giving  rise 
to  subperiosteal  abscess,  especially  in  the  ribs. 

326 


Differential  Diagnosis.  In  some  cases  tuber- 
culosis of  bone  may  be  mistaken  for  the  chronic  forms 
of  pyogenic  osteomyehtis.  However,  tuberculous 
bone  disease  can  nearly  always  be  recognized  by  its 
typical  situations,  its  characteristic  pus,  its  small 
sequestra,  its  slight  tendency  to  new  bone  formation, 
and  by  the  presence  of  tuberculosis  of  the  lungs.  In 
many  cases  the  diagnosis  is  assisted  by  the  X-rays. 
Some  cases  may  be  mistaken  for  syphilitic  bone 
disease.  In  doubtful  cases  diagnosis  can  be  settled 
by  incision. 

Treatment.  As  soon  as  tuberculous  disease  of 
bone  is  diagnosed  (by  the  X-rays  early  diagnosis  can 
be  made),  the  disease  must  be  radically  removed, 
without  interfering  too  much  with  function.  The 
bone  must  be  freely  exposed,  the  diseased  parts 
removed  by  the  gouge  or  sharp  spoon,  and  the  wound 
plugged  for  some  time  with  iodoform  gauze.  In  the 
extremities  immobilization  is  necessary.  Later  on, 
iodoform-glycerin  emulsion  may  be  injected  into  the 
bone  cavity.  Tuberculous  foci  can  be  treated  in 
this  way  in  the  bones  of  the  face,  the  cranial  bones, 
the  sternum  and  the  ilium. 

In  cases  of  tuberculous  disease  of  the  vertebrae 
(tuberculous  spondylitis  or  Pott's  disease)  operative 
interference  should  be  limited  to  the  evacuation  of 
abscesses,  which  often  point  on  the  inner  side  of  the 
thigh  below  Poupart's  ligament,  and  injection  of 
iodoform-glycerin  emulsion.  Operation  on  the  ver- 
tebrae themselves  is  likely  to  injure  the  spinal  cord  or 
nerves.  These  cases  often  undergo  spontaneous 
cure  by  sinking  of  the  bodies  of  the  vertebra?,  result- 
ing in  kyphosis.  These  cases  require  immobiliza- 
tion by  extension  splints  and  later  on  by  plaster  of 
Paris  jackets.  Extensive  bone  disease  of  the  extremi- 
ties in  old  people  may  require  amputation  to  save  the 
patient  from  death  b\  pulmonary  tuberculosis;  on 
which  amputation  often  has  a  favorable  influence. 

327 


Treatment  of  tuberculous  bone  disease  by  passive 
hypersemia  is  only  of  use  when  combined  with  other 
methods  of  treatment.  In  cases  of  pain  and  fatigue 
in  the  Hmbs  of  young  people,  occurring  without 
apparent  cause,  the  possibility  of  commencing  tuber- 
culous disease  of  the  bones  or  joints  must  always  be 
borne  in  mind.  Early  cases  often  recover  after  pro- 
longed immobilization  without  operation.  Bones 
which  have  been  affected  by  tuberculosis  must  be 
protected  from  injury,  which  may  start  the  disease 
afresh. 

Tuberculosis  of  Joints.  The  joints  are  often 
affected  with  tuberculosis,  generally  by  extension 
from  tuberculosis  of  the  bones.  Infection  of  the 
joints  may  also  take  place  through  the  blood,  but 
primary  tuberculosis  of  joints  is  rare.  In  most  cases 
both  the  synovial  membrane  and  the  articular  ends  of 
the  bones  are  affected.  The  knee  and  hip  joints  are 
most  often  attacked;  after  these  the  wrist  and  elbow. 
Tuberculous  joint  disease  is  most  common  before 
puberty,  but  it  also  occurs  at  an  advanced  age. 

The  tubercle  bacilli  give  rise  to  the  formation  of 
granulation  tissue  and  effusion  in  the  joint.  In  the 
mildest  forms  there  may  be  only  serous  effusion 
(hydrops),  but  more  commonly  the  effusion  is  sero- 
fibrinous. The  fibrin  forms  villous  deposits  on  the 
synovial  membrane  and  cartilage,  and  the  so-called 
"rice  bodies,"  which  are  lumps  of  loose  fibrin  in  the 
joint.  These  milder  forms  of  joint  disease  may  be 
included  under  the  name  of  articular  hydrops. 

The  second  form  of  tuberculous  arthritis  is  known 
as  fungoid  arthritis,  owing  to  the  formation  of  fun- 
goid or  spongy  granulation  tissue,  which  gives  rise  to 
globular  swelling  of  the  joint.  In  these  cases  the 
whole  joint  is  filled  with  grayish-red  or  yellowish- 
white  granulations,  and  there  is  only  slight  exudation. 
The  fungous  granulations  tend  towards  caseous 
degeneration,  and  after  a  time  to  suppuration.     This 

328 


form  of  tuberculous  arthritis  does  not  remain  limited 
to  the  joint  but  soon  extends  to  the  Hgaments  and 
periarticular  tissue,  and  eventually  to  the  subcuta- 
neous tissue  and  skin  (Figs.  125  and  126). 

A  third  form  is  fibrous  arthritis,  in  which  there  is  a 
formation  of  hard  fibrous  tissue  in  the  joint.  This 
form  is  called  caries  sicca  by  Volkmann.  It  is  com- 
mon in  the  shoulder  and  hip  joints,  and  is  character- 
ized by  a  great  tendency  to  cause  atrophy,  of  the 
articular  end  of  the  bone,  giving  rise  to  dislocations 
and  also  to  muscular  atrophy. 

In  distinction  to  the  above  atrophic  form,  there  is 
another  form  of  fibrous  arthritis  causing  globular 
swelling  of  the  joint  from  the  abundant  formation  of 
fibrous  tissue.  This  is  especially  common  in  the 
knee  joint  and  may  be  mistaken  for  bone  tumor.  It 
is  known  as  "white  swelling"  or  tumor  albus,  owing 
to  the  white  anaemic  appearance  caused  by  pressure 
of  the  fibrous  tissue  on  the  skin. 

A  fourth  form  of  tuberculous  joint  disease  is  furu- 
lent  arthritis.  This  is  often  due  to  mixed  infection 
of  one  of  the  above-mentioned  forms  with  staphylo- 
cocci— for  example,  through  a  fistula  in  the  skin. 
However,  purulent  arthritis  sometimes  occurs  quite 
suddenly,  especially  in  children. 

In  all  these  forms  of  tuberculous  arthritis  the  car- 
tilage may  be  destroyed  by  the  fibrinous  exudation. 
In  cases  of  fibrinous  hydrops,  and  in  caries  sicca,  the 
destructive  action  is  generally  limited  to  the  cartilage; 
but  in  the  fungoid  and  purulent  forms  of  arthritis  the 
whole  epiphysis  may  be  destroyed,  and  the  infection 
may  spread  to  the  diaphysis.  Besides  this,  multiple 
abscesses  often  develop  at  some  distance  from  the 
joint.  The  greater  the  destruction  of  the  joint  the 
more  abnormal  are  the  positions  of  the  afi'ected  limb. 
The  affected  joint  assumes  the  position  in  which  its 
capsule  has  the  greatest  capacity  {i.e.  the  position  in 
which  the  capsule  is  fully  distended).  For  this  rea- 
son the  knee  joint  is  in  the  position  of  flexion,  the  hip 

329 


joint  in  the  position  of  abduction  and  flexion,  the 
elbow  joint  in  the  position  of  flexion,  and  the  shoulder 
joint  in  the  position  of  external  rotation.  Fibrous  or 
bony  anchylosis  may  occur  in  these  positions ;  also  in 
positions  of  subluxation  or  dislocation. 

Tuberculous  arthritis  generally  begins  with  pain, 
which  is  often  remote  from  the  affected  joint;  e.g.  in 
disease  of  the  hip  joint  pain  is  referred  to  the  inner 
side  of  the  knee.  This  is  followed  by  slight  rises  of 
temperature  and  pain  in  the  region  of  the  affected 
joint.  Movement  of  the  joint  is  avoided,  the  whole 
joint  becomes  swollen,  and  characteristic  positions 
are  assumed  by  the  different  joints.  In  hydrops  there 
is  fluctuation.  In  fungoid  arthritis  the  whole  joint 
is  filled  with  soft,  spongy  tissue,  causing  balloon-like 
swelling  of  the  joint  (ballooning) ;  this  spongy  tissue 
extends  to  the  periarticular  tissue  and  reaches  the  skin, 
which  becomes  reddish  blue,  and  later  on  breaks 
down  into  tuberculous  ulcers  and  fistulas  (Fig.  Via). 

Diagnosis  is  generally  easy  in  cases  with  a  fistula 
discharging  characteristic  thin  tuberculous  pus  mixed 
with  caseous  debris  and  fragments  of  sequestrum. 
In  other  cases  there  is  evidence  of  tuberculosis  in 
the  lungs  or  other  organs.  The  fibrous  forms 
(caries  sicca)  are  characterized  by  the  marked  atro- 
phy of  the  joint,  the  abnormal  positions,  and  the 
muscular  atrophy  and  complete  loss  of  function. 
White  swelling  is  recognized  by  the  extensive  tumor- 
like swelling  covered  by  white  skin  (Fig.  1'28).  In 
purulent  arthritis  there  is  redness  and  swelling  of  the 
skin  with  high  temperature.  In  doubtful  cases  an 
incision  will  make  the  diagnosis  clear. 


*o" 


Differential  Diagnosis.  Tuberculous  hydrops 
may  be  mistaken  for  traumatic  effusion,  gonorrheal 
arthritis  or  syphilitic  arthritis.  The  diagnosis 
depends  on  the  historv'  of  the  case  and  thorough 
examination  of  the  whole  body.  In  doubtful  cases 
the  joint  may  be  punctured,  or  inoculation  of  the 

330 


t> 


guinea  pig  may  be  performed.  Acute  forms  of  fun- 
goid tuberculous  arthritis  can  hardly  be  mistaken 
for  other  affections.  In  cases  where  complete  heal- 
ing of  the  joint  has  taken  place,  with  bony  anchylosis, 
it  is  sometimes  impossible  to  distinguish  tuberculous 
cases  from  joint  disease  secondary  to  pyogenic  osteo- 
myelitis of  the  diaphysis.  In  old  people  healed 
tuberculous  joints  may  be  mistaken  for  arthritis 
deformans  or  chronic  rheumatism.  Purulent  tuber- 
culous arthritis  often  resembles  acute  pyogenic  osteo- 
myelitis. In  young  children  especially,  when  the 
disease  begins  with  rigors,  high  fever  and  constitu- 
tional disturbance,  diagnosis  is  often  only  made  after 
incision. 

The  prognosis  of  tuberculous  arthritis  is  more 
favorable  in  young  individuals  than  in  old  people. 
Chronic  tuberculous  arthritis  may  give  rise  to  miliary 
tuberculosis,  or  to  amyloid  degeneration  of  the  inter- 
nal or  trans. 


&■• 


Treatment.  In  its  early  stages  tuberculous 
arthritis  may  be  cured  by  immobilization  by  means 
of  extension  splints  or  plaster  of  Paris  casings.  Con- 
serv'ative  treatment  should  always  be  adopted  in  the 
early  stages.  Hydrops  may  be  treated  by  repeated 
puncture,  injection  of  iodoform-glycerin  emulsion  or 
alcohol  and  immobilization  of  the  joint.  Recurrence 
is  common,  and  complete  restoration  of  function  sel- 
dom occurs.  The  joints  should,  therefore,  be 
allowed  to  anchylose  in  the  most  useful  position. 
When  abscesses  and  fistulas  form,  and  when  an 
extensive  focus  of  bone  disease  is  shown  by  the 
X-rays,  conservative  treatment  must  be  abandoned. 

In  fibrous  arthritis,  caries  sicca  and  white  swelling, 
resection  of  the  joint  should  be  performed  as  early  as 
possible,  to  prevent  muscular  atrophy.  In  the 
shoulder  joint  resection  gives  good  results;  but  in 
the  knee  joint,  bony  anchylosis  in  the  straight  position 
is    the   only   possible   result.     In   fungous    arthritis, 

331 


especially  in  young  patients,  operation  may  be 
limited  to  opening  the  joint  and  carefully  removing 
all  tuberculous  disease  (arthrectomy).  The  capsule 
of  the  joint  must  be  excised  wherever  it  is  diseased, 
and  tuberculous  foci  in  the  cartilage  and  bone 
removed  with  the  gouge.  In  young  subjects  a 
typical  resection  of  the  joint  is  to  be  avoided,  owing 
to  interference  with  the  growth  of  the  limb  by  exten- 
sive removal  of  the  epiphyses. 

In  adults,  on  the  other  hand,  the  joint  may  be 
resected  and  all  diseased  parts  carefully  removed. 
If  the  medullary  cavity  is  found  to  be  diseased,  after 
resection  of  the  epiphysis,  it  must  be  scraped  out. 
Abscesses  and  fistulas  require  incision  and  scraping. 
In  purulent  arthritis  the  joint  must  be  freely  opened ; 
in  advanced  cases  resection  is  necessary.  In  exten- 
sive tuberculous  arthritis  with  tuberculous  disease  of 
the  neighboring  bones  and  soft  parts,  amputation 
may  be  necessary,  especially  in  old  people  (Fig.  130). 

After  operation  the  joint  must  be  plugged  with  iodo- 
form gauze,  drained,  and  immobilized.  Joints  which 
have  become  healed  in  abnormal  positions  may  be  forc- 
ibly corrected  under  an  anaesthetic  when  the  anchylosis 
is  fibrous ;  but  there  is  danger  of  rupture  of  the  vessels 
and  consequent  gangrene  (Fig.  132).  It  is  better  to  treat 
fibrous  anchylosis  by  gradual  extension;  while  bony 
anchylosis  in  a  bad  position  may  require  resection. 

After  operations  on  joints,  these  should  be  pro- 
tected by  light  splints  {e.g.  poroplastic  casings)  till 
the  end  of  the  period  of  growth  in  children,  and  for 
some  years  in  adults.  The  disadvantage  of  this 
apparatus  is  the  causation  of  muscular  atrophy.  On 
the  other  hand,  after  resection  of  the  knee  joint  in 
young  subjects,  the  knee  often  becomes  flexed,  even 
after  bony  anchylosis,  requiring  further  resection. 

Tuberculosis  of  other  Tissues.  Tuberculosis 
of  the  mucous  membranes  occurs  in  the  buccal  cavity, 
the  tongue,  lips,  larynx,  small  intestine  and  rectum, 

332 


and  is  generally  secondary  to  tuberculosis  of  the 
lungs.  Von  Bergmann  has  observed  a  case  of  tuber- 
cular infection  of  the  mouth,  from  a  culture  of 
tubercle  bacilli,  which  was  cured  by  excision. 
Tuberculosis  of  the  mucous  membranes  develops  in 
the  form  of  small,  reddish-gray  nodules,  which  break 
down  into  small  easily  bleeding  ulcers  with  ragged 
edges  and  a  yellow  caseous  surface.  These  are  best 
treated  by  cauterization  with  strong  lactic  acid. 
Fistula  of  the  rectum,  which  is  common  in  intestinal 
tuberculosis,  requires  incision.  Tuberculosis  of  the 
ileo-caecal  region,  causing  fibrous  stricture,  may 
require  resection  of  the  gut. 

Tuberculous  peritonitis,  which  gives  rise  to  exuda- 
tion and  the  formation  of  extensive  adhesions,  is  im- 
proved by  laparotomy  and  removal  of  the  exudation. 
Purulent  tuberculous  effusion  into  the  pleural  cavity 
should  be  evacuated  by  resection  of  the  ribs.  Tuber- 
culosis of  the  testicles  and  kidneys  necessitates 
removal  of  these  organs.  Tuberculosis  of  the  blad- 
der should  be  treated  by  irrigation  and  the  internal 
administration  of  guiacol.  It  has  been  attempted  to 
remove  isolated  foci  of  tuberculosis  in  the  lungs  by 
operation. 

Treatment  of  the  general  condition  of  the  patient 
is  necessary  in  all  forms  of  tuberculous  disease. 

Miliary  tuberculosis,  which  may  develop  after 
extensive  operations,  such  as  removal  of  tuberculous 
glands  in  the  neck,  or  after  breaking  down  joint 
adhesions,  is  due  to  dissemination  of  tubercle  bacilli 
in  the  blood,  and  may  take  the  form  of  a  typhoid 
condition,  pulmonary  disease  or  meningitis.  It  is 
not  amenable  to  surgical  treatment. 


333 


LYMPHOMATA  COLLI  TUBERCULOSA 

{T uherculmis  LympJioma  of  tJie  Neck) 
Plate  XC\T:n,  Fig.  124. 

This  is  a  case  of  tuberculosis  of  the  submaxillary 
and  cervical  glands.  The  patient  suffered  since  youth 
from  eczema  of  the  face  and  inflammation  of  the 
eyelids.  A  swelling  gradually  formed  in  the  neck 
over  which  the  skin  became  livid.  A  series  of  swell- 
ings of  different  sizes  were  felt  under  the  skin,  which 
was  movable  over  them.  Some  of  these  were  hard, 
others  soft  and  fluctuating.  There  was  no  sign  of 
pulmonary  tuberculosis.  The  glands  were  removed 
through  an  incision  along  the  inner  border  of  the 
sterno-mastoid.  In  removing  glands  with  suppura- 
tion in  their  interior,  care  must  be  taken  not  to  break 
into  them  and  thus  infect  the  wound.  The  wound 
was  plugged  with  iodoform  gauze  and  sutured,  leav- 
ing a  space  for  drainage  at  the  lower  end. 


334 


Bockenlieimer,  Atlas. 


Tab.  XCAIII. 


Tig.  124.     Lyniplioniata  culli  tuberculosa. 


Rcbman  C'oiiin.Tiu'    NVw-Vnrif. 


Bockenheimer,  Atlas. 


Tab.  XCIX. 


Fig.  125.    Artliritis  tuberculosa  fungosa   —   Ankylosis  genus  fibrosa   —   Abscessus  frigidus. 


Rcbman  Company,  New-Vork. 


ARTHRITIS  TUBERCULOSA  FUNGOSA 

(FiDKioid  fiibcretdous  arthritis) 
ANKYLOSIS  GENUS  FIBROSA  (Fibmu.'s  anchylosis) 
ABSCESSUS  FRIGIDUS    {Cold  Abscess) 

Plate  XCIX,  Fig.  1-23. 

This  is  a  case  of  multiple  tuberculosis  of  the  joints, 
bones  and  soft  parts,  together  with  pulmonary  tuber- 
culosis, occurrinfj  in  a  vounc;  individual.  The  rijjht 
leg  was  useless  owing  to  extensive  disease  of  the  hip 
joint.  The  thigh  was  flexed,  and  X-ray  examination 
showed  destruction  of  the  upper  margin  of  the 
acetabulum  and  displacement  of  the  head  of  the 
femur  onto  the  ilium.  In  the  middle  of  the  flexor 
surface  of  the  thigh  is  a  healed  fistula  due  to  a  bur- 
rowing abscess.  In  the  middle  of  the  extensor  sur- 
face of  the  thigh  is  a  clearly  visible  swelling  due  to  a 
burrowing  abscess,  which  is  common  in  this  situation 
in  tuberculous  arthritis  of  the  hip  joint,  and  in  tuber- 
culous disease  of  the  vertebrae;  in  the  latter  case  the 
abscess  burrows  along  the  psoas  muscle.  Fluctua- 
tion was  present,  but  the  skin  was  intact  (cold 
abscess).  The  abscess  was  evacuated  by  puncture 
and  injected  with  iodoform-glycerin.  Resection  of 
the  hip  joint  was  postponed  till  the  general  condition 
of  the  patient  was  improved. 

The  knee  joint  was  also  the  seat  of  old  tuberculous 
arthritis  of  the  fibrous  type,  which  had  led  to  anchy- 
losis at  right  angles.  This  was  corrected  under  an 
anaesthetic  by  forced  movement  and  an  extension 
splint. 

On  the  inner  side  of  the  ankle  joint  are  character- 
istic tuberculous  ulcers,  with  irregular  undermined 
borders  and  yellow  caseous  surface.  Thin,  greenish 
pus  was  discharged  by  pressure.     The  X-rays  showed 

335 


a  focus  of  tuberculous  disease  in  the  astragalus,  which 
had  broken  into  the  joint.  Tuberculous  arthritis  of 
the  ankle  joint  more  often  breaks  through  on  the 
outer  side.  Hydrops  is  rare  in  this  situation.  The 
joint  is  usually  filled  with  fungoid  tuberculous  tissue 
which  extends  to  the  periarticular  tissues.  In  Fig. 
125  the  foot  w'as  in  the  position  of  equinus  owing  to 
absence  of  function  and  neglect  of  treatment.  Owing 
to  the  extensive  nature  of  the  disease  conservative 
treatment  was  out  of  the  question.  The  joint  was 
freely  laid  open  and  all  tuberculous  matter  removed 
(arthrectomy).  The  limb  was  immobilized  by  plas- 
ter of  Paris  bandages  and  extension  applied. 


336 


fiockenheimer,  Atlas. 


Tab.  C. 


Fig.  120.    Arthritis  tuberculosa-puruleiita. 


Fig.  127.    Arthritis  tuberculosa  fibrosa 
Anlsvlosis  ossea   —  Subluxatio. 


Kebman  Company,  Ncw-\'ork. 


ARTHRITIS  TUBERCULOSA  PURULENTA 

{Piiruhnt  Tuberculous  Arthritis) 
Plate  C,  Fig.  12b. 

This  figure  shows  a  case  of  purulent  tuberculous 
arthritis  of  the  ankle  joint.  This  form  of  arthritis  is 
common  in  children,  more  often  affecting  the  knee- 
joint.  It  begins  with  fever  and  rigors,  and  the  rapid 
formation  of  abscess,  and  may  be  mistaken  for 
arthritis  due  to  staphylococci  or  other  pus  cocci. 
Two  incisions  were  made  on  the  outer  and  inner 
sides  of  the  joint,  and  characteristic  thin  pus  mixed 
with  fibrin  was  evacuated.  The  joint  was  then  put 
up  in  plaster  of  Paris.  Purulent  tuberculous  arthritis 
in  children  often  recovers  after  early  incision;  but 
there  is  generally  some  stifl'ness  in  the  joints,  so  that 
these  must  be  put  up  in  the  most  suitable  position 
for  future  use. 


337 


ARTHRITIS  TUBERCULOSA  FIBROSA 

{Fibrous  Tuberculous  Arthritis) 
ANKYLOSIS   OSSEA  (Bony  Anchylosis) 
SUBLUXATIO  (Sub-luxation) 

Plate  C,  Fig.  127. 

This  is  a  case  of  old-standing  fibrous  tuberculous 
arthritis  of  the  knee  joint  with  bony  anchylosis,  as 
shown  by  the  X-rays.  Owing  to  neglect  of  prolonged 
fixation  of  the  joint  in  the  straight  position,  flexion 
contracture  wuth  backward  displacement  of  the  tibia 
has  taken  place.  This  was  corrected  by  cuneiform 
osteotomy,  plaster  of  Paris  bandages,  and  later  on  a 
celluloid  casing. 


338 


Bockenlic'iiiier,  Atlas. 


lab.  CI. 


Fig.  128.    Arthritis  tuberculosa         Tumor  albus. 


Kebm.in  Coinp.aiiy,  Nc\\-\'ork. 


ARTHRITIS  TUBERCULOSA  FIBROSA 

(Fibrom  Titherculous  Arthritis) 
TUMOR  ALBUS  (White  Swelling) 

Plate  CI,  Fig.  128. 

This  form  of  tuberculous  arthritis  is  common  in 
the  knee  joint  in  adults.  It  consists  in  the  formation 
of  hard,  fibrous  tissue  in  the  joint  and  periarticular 
tissue,  and  gives  rise  to  a  tumor-like  swelling  of  the 
knee  and  adjacent  parts.  The  skin  is  white  from 
pressure  of  the  subjacent  mass;  hence  the  name 
white  swelling,  or  tumor  alhus.  In  Fig.  128  the 
disease  was  of  several  months'  duration,  and  was  as- 
sociated with  tuberculosis  of  the  lungs.  The  patient 
attributed  the  affection  of  the  knee  to  an  injury. 
The  X-rays  showed  tuberculosis  of  the  bones,  as  well 
as  of  the  synovial  membrane — a  common  combination 
in  tubercle  of  the  knee  joint.  Similar  swelling  occurs 
in  tuberculous  hydrops,  the  simplest  form  of  tubercu- 
lous joint  disease.  Effusion  into  the  joint  often  pre- 
cedes the  arthritis  and  is  recognized  by  halottement 
of  the  patella,  which  is  raised  from  the  femoral 
condyles  by  the  fluid  in  the  joint.  The  fluid  is 
generally  sero-fibrinous,  with  numerous  free  "rice 
bodies."  More  common  than  the  fibrous  form  is 
fungoid  arthritis,  which  may  go  on  to  suppuration 
and  cause  much  destruction  in  and  around  the  joint. 
In  all  forms  of  tuberculous  arthritis  of  the  knee,  the 
joint  is  in  a  position  of  flexion  and  valgus.  The 
muscles  of  the  leg  become  atrophied,  and  there  is 
retarded  growth  of  the  leg. 

In  Fig.  128,  the  joint  was  resected  and  all  tuber- 
culous tissue  removed.     The  articular  ends  of  both 

339 


bones  were  extensively  diseased  and  the  cartilages 
destroyed.  In  resection  of  the  articular  surfaces  it 
is  necessary  to  saw  the  bones  so  that  the  limb  can  be 
brought  into  a  straight  position. 


340 


Bockenlieimer,  Atlas. 


Tab.  CII. 


Rrbiii.111  roiiip.iiiy,  Nmv  \'oik. 


TUBERCULOSIS  TESTIS    (Tubercuhxh  of  the  Testicle) 
Plate  CII,  Fig.  Ui). 

Tuberculosis  of  the  testicle  begins  in  the  epididymis 
and  extends  to  the  testicle.  It  often  affects  both 
testicles.  There  is  often  tuberculosis  of  the  bladder, 
kidneys  and  seminal  vesicles,  and  nearly  always  pul- 
monary tuberculosis.  In  the  early  stages  of  the  dis- 
ease hard  nodules  are  felt  in  the  testicle.  Later  on 
these  nodules  become  soft  and  fixed  to  the  skin, 
which  breaks  down  and  forms  a  typical  tuberculous 
ulcer  (Fig.  129).  In  advanced  cases  there  may  be 
several  ulcers  and  fistulas  in  the  scrotum,  discharging 
caseous  pus.  The  spermatic  cord  is  usually  thick- 
ened, and  the  seminal  vesicles  can  sometimes  be  felt 
enlarged  by  rectal  examination.  The  prostate  is 
seldom  affected  by  tuberculosis. 

Fig.  129  shows  extensive  disease  of  the  left  testicle 
and  epididymis.  The  skin  is  thin  in  several  places, 
and  ulcerated  in  one  place.  The  spermatic  cord  was 
thickened,  but  no  disease  was  found  in  the  bladder, 
seminal  vesicles,  prostate  or  kidneys.  There  was 
advanced  tuberculosis  of  the  lungs.  In  the  early 
stages  of  the  disease  the  tuberculous  foci  may  be 
incised  and  scraped,  but  more  advanced  cases  require 
castration  (Fig.  129).  The  testicle  when  removed 
showed  miliary  nodules  in  some  parts,  abscesses  and 
caseous  foci  in  other  parts. 

In  its  early  stage  tuberculous  testicle  may  be  mis- 
taken for  gumma,  but  the  latter  begins  in  the  testicle, 
and  takes  a  long  time  to  break  through  the  skin. 
IVIalignant  growths  cause  more  rapid  enlargement  of 

the  testicle. 

341 


TUBERCULOSIS  MANUS    (Tubereidofds  of  the  Hand) 
Plate  cm.  Fig.  130. 

In  an  old  woman,  who  suffered  from  advanced 
pulmonary  tuberculosis,  a  swelling  gradually  devel- 
oped over  the  left  wrist,  causing  pain  on  movement. 
The  swelling  gradually  extended  over  the  back  of 
the  hand,  preventing  movement  of  the  fingers.  Two 
typical  tuberculous  ulcers  discharging  thin  pus  and 
caseous  matter  developed  on  the  back  of  the  hand. 
Passive  movement  at  the  wrist  joint  was  very  limited 
and  caused  crepitation.  The  X-rays  showed  tuber- 
culous disease  of  the  carpal  and  metacarpal  bones. 
Tuberculosis  of  the  wrist  joint  in  old  people  is  often 
so  extensive  as  to  require  amputation.  In  this  case 
the  joint  was  resected,  the  cavity  filled  with  iodoform 
glycerin,  and  the  limb  put  up  in  plaster  of  Paris. 

The  operation  showed  the  presence  of  tuberculosis 
of  the  tendon-sheaths  (tendovaginitis),  the  tendons 
being  imbedded  in  granulation  tissue.  Tuberculous 
tendovaginitis  is  more  common  in  the  upper  extrem- 
ity, and  occurs  apart  from  bone  disease.  It  may 
take  the  form  of  tuberculous  hygroma,  with  sero- 
fibrinous fluid  and  crepitation  on  movement  of  the 
tendons ;  or  a  fungoid  form  in  which  the  tendons  are 
imbedded  in  spongy  granulations.  Tuberculous  dis- 
ease of  the  tendon-sheaths  is  most  extensive  when  it 
is  secondary  to  old-standing  tuberculous  joint  dis- 
ease, as  in  the  above  case.  The  treatment  consists 
in  removing  the  diseased  tissue  without  injuring  the 
tendons;  a  difficult  operation  in  the  case  of  flexor 
tendons,  on  account  of  the  vessels  and  nerves. 


342 


Bockenheiiiier,  Atlas. 


lab.  cm 


I'ig.  ]'W.    Tuborculnsis  in.inus. 


Rebnnn  fnninnnv.  Mpt- \'nrl.- 


Bockeiiheimer,  Atlas. 


Tab.  Cl\'. 


o 


CI 

CO 


CO 

I 


OJ 


o 

CO 


l?ebninn  Company,  New-Vork 


OSTITIS   TUBERCULOSA    (Tuberculous  Osteitis) 
SPINA   VENTOSA    {Dadyliih) 

Plate  CIV,  Fig.  131. 

Tuberculosis  of  the  phalanges  begins  in  the  me- 
dulla and  extends  to  the  cortex  and  periosteum.  The 
whole  diaphysis  may  be  destroyed  by  suppuration 
and  caseation,  while  the  periosteum  forms  a  thin 
shell  of  new  bone.  The  bone  then  appears  swollen, 
as  if  inflated  (spina  ventosa).  The  disease  generally 
aflFects  several  phalanges  of  several  fingers  on  both 
hands,  and  is  often  found  in  the  children  of  tubercu- 
lous parents.  The  destructive  process  is  more  severe 
than  in  any  other  form  of  tuberculous  osteitis,  sev- 
eral phalanges  being  often  completely  destroyed. 
Fistulas  form  in  the  oedematous  skin  and  discharge 
caseous  matter.  Growth  of  the  fingers  is  interfered 
with,  so  that  they  often  form  deformed  stumps  after 
the  disease  has  healed.  The  disease  is  often  over- 
looked as  it  is  at  first  painless;  but  early  diagnosis 
can  be  made  by  the  X-rays  which  show  the  changes 
in  the  bone. 

Syphilitic  dactylitis  difi^ers  in  causing  less  destruc- 
tion of  bone,  and  in  the  usual  absence  of  suppuration 
and  necrosis;  but  the  diagnosis  often  depends  on 
other  signs  and  history  of  syphilis  or  tuberculosis. 

Treatment  consists  in  early  incision,  scraping, 
and  plugging  with  iodoform  gauze. 


343 


GANGILENA  PEDIS  HUMroA  (Moist  Gangrene  of  the  Foot) 
Plate  CIV,  Fig.  132. 

This  case  is  of  special  interest,  gangrene  of  the 
foot  having  developed  after  forcible  correction  of 
flexion  contracture  due  to  tuberculosis  of  the  hip 
joint.  Soon  after  this  operation  the  toes  became 
cold,  blue  and  flexed,  and  finally  black.  As  the  gan- 
grene was  limited  to  the  anterior  portion  of  the  foot, 
it  is  probable  that  the  injury  was  to  the  intima  only 
and  not  a  complete  rupture  of  the  femoral  artery, 
and  that  gangrene  was  due  to  thrombosis  of  the  vessel. 

The  figure  shows  gangrene  gradually  involving  the 
anterior  part  of  the  foot.  In  the  first  and  fifth  toes 
necrotic  bone  emerges  from  fistulas  in  the  skin.  In 
the  sole  of  the  foot  a  wide  zone  of  demarcation  is  seen, 
covered  with  granulations,  and  separating  the  gan- 
grenous part  from  the  healthy  tissues  behind.  When 
the  line  of  demarcation  has  extended  all  round  the 
foot,  the  gangrenous  part  can  be  removed,  and  the 
wound  can  be  repaired  by  an  osteoplastic  operation. 
The  different  forms  of  gangrene  will  be  described 
with  the  next  plate. 


344 


Bockenheimer,  Atlas. 


Tab.  CV. 


Fig.  133.   Oangraena  sicca  brachii  --  AUuiiificatio. 


GAWGIL«NA  SICCA  BRACHII— MUMMIFICATIO 

{Dri/  Gangrene  of  the  Arm) — (Mummification) 
Plate  CV,  Fig.  133. 

The  term  gangrene  is  applied  to  extensive,  pro- 
gressive death  of  the  superficial  tissues  of  the  body; 
the  term  necrosis  to  death  of  the  deeper  structures 
(fascia,  muscle  and  bone).  The  bones  have  a  greater 
power  of  resistance  than  the  skin,  which  may  become 
gangrenous  after  slight  disturbance  in  the  circulation. 
Under  certain  conditions,  e.g.  after  cutting  off  the 
blood  supply,  the  whole  peripheral  part  of  a  limb 
may  become  destroyed;  but,  as  the  death  of  the 
tissues  is  first  noticed  in  the  skin,  it  is  spoken  of  as 
gangrene.  ^Vhen  the  process  consists  in  desiccation 
of  the  tissues  it  is  called  dry  gangrene;  when  it  ends 
in  liquefaction  from  the  invasion  of  putrefactive  bac- 
teria, it  is  called  moist  or  infective  gangrene.  Dry 
gangrene  may  change  to  moist  gangrene,  and  both 
processes  may  occur  simultaneously  in  different  parts 
of  the  same  limb,  when  one  part  becomes  infected 
and  the  other  does  not. 

The  extent  of  the  gangrene  varies  according  to 
the  cause;  it  may  be  circumscribed  (after  local  appli- 
cations, such  as  carbolic  acid),  or  progressive  (after 
embolism).  In  both  forms  the  dead  tissue  becomes 
separated  from  the  living  by  a  zone  of  demarcation. 
The  zone  of  demarcation  forms  a  groove  filled  with 
granulation  tissue  (Fig.  13^2).  It  may  be  circular 
(Fig.  135)  or  irregular  (Figs.  133  and  134). 

In  the  early  stage  of  dry  gangrene  the  condition 
resembles  that  of  ischajmic  muscular  contracture 
(Fig.  63),  especially  when  the  condition  is  due  to 
plugging  of   the  blood-vessels.     The  skin  becomes 

345 


dry,  shrunken  and  parchment-like.  In  the  extremi- 
ties the  peripheral  parts  are  flexed  and  immovable. 
The  skin  becomes  gradually  yellowish  brown  and 
finally  black  (Fig.  133).  All  the  subjacent  structures 
may  undergo  dry  atrophy.  The  dead  tissue  is  grad- 
ually separated  by  the  zone  of  demarcation,  and  the 
whole  of  an  extremity  may  undergo  spontaneous 
separation. 

While  in  dry  gangrene  there  is  diminution  in  vol- 
ume and  charring  of  the  affected  part;  in  moist 
gangrene  there  is  increase  in  volume,  due  to  preceding 
oedema.  In  moist  gangrene  there  is  more  or  less 
liquefaction,  decomposition  or  putrefaction,  due  to 
putrefactive  bacteria.  The  skin  is  cool  and  moist, 
and  the  epidermis  becomes  raised  in  bullae  containing 
blood-stained  fluid.  After  rupture  of  the  bullae  the 
skin  is  reddish  brown  (Fig.  109).  Finally  the  tissues 
become  disintegrated  and  smell  horribly;  lymphan- 
gitis, lymphadenitis  and  general  infection  then  follow. 

In  both  forms  of  gangrene  the  skin  is  at  first  pale 
and  cold,  and  then  shows  bluish  patches  in  various 
places,  often  without  any  direct  connection.  Con- 
tractures and  loss  of  movement  indicate  the  occur- 
rence of  total  gangrene,  whether  moist  or  dry.  How- 
ever, the  difference  in  volume  between  the  two  forms 
is  apparent  from  the  beginning. 

A  deep  groove  of  demarcation  also  forms  in  moist 
gangrene,  separating  the  dead  from  the  livmg  tissue, 
and  spontaneous  separation  may  occur  if  the  patient 
does  not  succumb  to  general  infection.  In  less 
extensive  cases  of  moist  gangrene  we  can  wait  for 
the  line  of  demarcation  to  form;  but  the  gangrenous 
part  must  be  removed  if  there  are  rigors  and  high 
temperature. 

The  etiology  of  gangrene  is  complex,  but  it  is 
always  due  to  disturbance  of  the  circulation.  The 
blood-vessels  may  be  affected  directly  or  indirectly. 
Senile  gangrene  in  old  people  is  due  to  arterioscle- 
rosis.    The  loosened   intima  of  the  small  terminal 

34G 


vessels  (also  in  the  larger  vessels)  gives  rise  to  throm- 
bosis, causing  death  of  the  peripheral  tissues  sup- 
plied by  these  vessels,  especially  when  the  vessels 
which  carry  on  collateral  circulation  are  themselves 
diseased.  In  this  way  the  toes  or  the  whole  leg  may 
become  gangrenous.  In  these  cases  the  typical 
changes  of  gangrene  are  preceded  by  pain.  Gan- 
grene of  the  lower  extremities  in  diabetic  subjects  is 
generally  caused  by  disease  of  the  vessels. 

In  younger  people  gangrene  of  the  peripheral 
parts  of  the  extremities  may  be  caused  by  disease  of 
the  intima  of  the  smaller  vessels  (endarteritis  oblit- 
erans). This  is  usually  of  syphilitic  origin.  In 
these  cases  there  are  severe  intermittent  pains,  caus- 
ing the  patient  to  limp  (intermittent  claudication). 
Both  feet  are  usuallv  affected,  and  become  bluish 
red.  After  some  years  gangrene  gradually  super- 
venes, often  taking  months  to  develop  (angioscle- 
rotic gangrene).  The  patients  suffer  severe  pain, 
especially  on  contact  or  exposure  to  cold. 

Embolism  of  the  main  arteries  {e.g.  from  heart 
disease)  causes  sudden  and  extensive  gangrene  of 
the  upper  or  lower  extremities.  (Embolic  gangrene). 
Sudden  gangrene  may  also  be  caused  by  rupture  or 
ligation  of  a  main  artery.  Certain  nervous  diseases 
may  cause  gangrene  by  vaso-motor  constriction  of 
the  vessels  (angio-neurotic  gangrene).  The  latter 
affection  occurs  symmetrically  in  both  feet  and  is 
known  in  its  early  stages  as  Raynaud's  disease.  It 
is  generally  preceded  by  parsesthesias  and  diminution 
in  the  sense  of  temperature. 

Gangrene  may  also  occur  after  extensive  burns 
and  frostbite;  after  local  application  of  carbolic  acid, 
lysol  and  alcohol;  after  injection  of  adrenalin  into 
the  tissues,  and  after  the  internal  administration  of 
ergotin  (hands,  feet  and  ears).  In  all  these  cases 
gangrene  is  caused  by  thrombosis  of  the  vessels.  In 
the  same  way  erysipelas  and  phlegmonous  inflamma- 
tion  may   cause  gangrene   of   the  skin   and   deeper 

347 


tissues.     Gangrene  of  the  skin  may  also  be  caused 
by  the  X-rays  and  by  radium. 

Differential  Diagnosis.  The  appearance  of  gan- 
grene, when  fully  developed,  is  so  characteristic  that 
it  can  hardly  be  mistaken  for  any  other  condition. 
The  two  forms  of  gangrene  are  also  sharply  defined 
from  each  other.  Dry  gangrene  might  be  mistaken 
for  burns  of  the  third  or  fourth  degrees,  if  signs  of 
the  first  and  second  degree  of  burn  were  not  always 
present  in  the  neighborhood.  Moist  gangrene  might 
be  mistaken  for  putrefactive  phlegmon,  especially 
with  progressive  gaseous  phlegmon  (Fig.  109),  if 
the  signs  of  general  infection  were  not  present  at  an 
early  stage.  The  history  and  a  thorough  examina- 
tion will  not  only  establish  the  diagnosis,  but  in  most 
cases  will  decide  the  cause  of  the  gangrene. 

The  prognosis  naturally  depends  on  the  cause  and 
on  the  extent  of  the  gangrene.  Angiosclerotic  gan- 
grene extends  very  slowly;  it  may  remain  stationary; 
or  parts  w'hich  appeared  to  be  affected  may  recover. 
Plugging  of  a  large  vessel  causes  extensive  gangrene 
of  the  part  supplied  by  the  vessel.  Diabetic  gangrene 
and  senile  gangrene  are  characterized  by  their  pro- 
gressive course.  Gangrene  is  more  extensive  when 
there  is  much  cedema. 

Treatment.  Extensive  gangrenous  parts  should 
be  removed  after  a  zone  of  demarcation  has  formed. 
Before  this  takes  place  the  part  should  be  dressed 
with  aseptic  dressings  or  ointments.  In  moist  gan- 
grene of  an  extremity  early  removal  may  be  indicated 
in  order  to  prevent  general  infection.  In  gangrene 
due  to  syphilitic  endarteritis,  iodide  of  potassium 
and  mercury  should  be  given;  the  limb  should  be 
raised  and  enveloped  in  wool;  hot-air  treatment  is 
useful  for  the  pains;  alcohol  should  be  avoided: 
after  demarcation  has  formed,  amputation  should  be 
performed   in  the  most  conservative  way  possible. 

348 


In  embolic  and  in  diabetic  gangrene  high  amputation 
is  often  necessary. 

In  amputation  the  elastic  tourniquet  is  to  be 
omitted  in  cases  where  the  gangrene  is  due  to  changes 
in  the  vessels,  as  it  may  cause  further  gangrene  above 
the  point  of  amputation.  If  the  vessels  in  the  stump 
only  bleed  slightly,  this  shows  that  they  are  already 
affected  and  that  the  gangrene  will  probably  extend 
further.  The  veins  in  the  amputation-stump  bleed 
freely,  owing  to  the  absence  of  the  vis  a  tergo  due  to 
narrowing  of  the  arteries.  After  amputation  any 
pressure  of  the  dressings  is  to  be  avoided. 

Fig.  132  shows  a  typical  case  of  dry  gangrene  or 
mummification  of  the  arm,  affecting  all  the  tissues. 
The  fingers  are  contracted  and  blackish  brown  in  color. 
The  skin  is  hard.  In  the  forearm  commencing  gan- 
grene is  seen  in  the  yellow  leathery  skin.  The  line  of 
demarcation  is  seen  as  a  red  zone  formed  of  granula- 
tion tissue,  separating  the  dead  from  the  healthy  parts. 
After  the  line  of  demarcation  had  extended  all  round 
the  limb,  amputation  through  the  arm  was  performed. 

In  this  case  gangrene  was  due  to  rupture  of  the 
axillary  artery  during  an  operation  for  reduction  of 
an  old  dislocation.  In  old  dislocations  at  the  shoul- 
der joint  bloodless  reduction  is  generally  impossible 
and  may  cause  rupture  of  the  artery.  But  this  dis- 
advantage also  applies  to  reduction  by  open  opera- 
tion, for  the  displaced  vessels  are  liable  to  become 
damaged  by  pressure  of  the  dislocated  head  of  the 
humerus  and  are  easily  ruptured  during  reduction  of 
the  dislocation.  This  accident  may  be  avoided  by 
resection  of  the  head  of  the  humerus,  after  carefully 
separating  the  artery,  which  is  generally  united  to  it. 
The  incision  for  the  operation  is  the  same  as  for 
ligation  of  the  axillary  artery. 

This  case  also  shows  the  importance  of  early 
diagnosis  of  dislocation  of  the  humerus,  which  is 
easily  made  by  the  X-rays. 

349 


GANGRiENA  CUTIS  HUMID  A  — NECROSIS  FASCLE 

{Moist  Gangrene  of  the  Sinn) 
ULCUS   DECUBITALE    (Decubital  Ulcer— Bedsore) 
Plate  CVI,  Fig.  134. 

The  skin,  being  the  most  superficial  part  of  the 
body,  is  most  liable  to  injuries  which  may  cause 
gangrene.  It  has  also  less  power  of  resistance  than 
other  tissues.  Long-continued  pressure,  especially 
in  places  situated  over  the  bones,  may  cause  gan- 
grene of  the  skin.  In  this  way  gangrene  may  be 
caused  by  the  pressure  of  tight  bandages  or  splints; 
also  by  a  displaced  piece  of  bone  in  fractures;  by 
pressure  on  the  outer  side  of  the  foot  in  pes  varus; 
by  tight  sutures,  e.g.  after  amputation  of  the  breast, 
leaving  a  wide  space  to  be  closed. 

Uncleanliness,  loss  of  consciousness,  nervous 
diseases  (trophoneuroses,  syringomyelia,  hemiplegia, 
paraplegia,  tabes),  cachexia,  diabetes,  typhoid  fever, 
osteomyelitis,  phlegmonous  inflammation,  general 
infection  and  comatose  conditions,  all  predispose  to 
gangrene,  which,  in  emaciated  persons,  may  become 
very  extensive.  Gangrene  of  the  skin  caused  by  the 
pressure  of  oedema  and  gaseous  formation  in  the 
tissues  has  already  been  mentioned  (Figs.  91  and 
109).  After  operations,  gangrene  of  the  skin  (bed- 
sores) may  occur  over  the  heels,  buttocks,  spinous 
processes,  shoulder  blades  and  back  of  the  head,  if 
care  is  not  taken  to  change  the  position  of  the  patient 
and  apply  soft,  smooth,  protective  coverings. 

Gangrene  of  the  mucous  membranes  may  occur 
from  the  pressure  of  foreign  bodies;  for  instance,  in 
the  esophagus,  from  the  passage  of  bougies;  in  the 
intestine,  from  the  pressure  of  Murphy's  buttons;   in 

350 


Bockenheimer,  Atlas. 


Tab.  C\'l. 


r\g.  134.    Oangnieiia  liumida  cutis  -   Necrosis  fasciae  —   Ulcus  decubitale. 


Rebman  Company.  New-York. 


the  larynx,  after  intubation;  also  after  resection  of 
the  intestine  or  esophagus  when  the  united  ends  are 
under  great  tension. 

Gangrene  of  the  skin  begins  with  pain  and  redness; 
then  slight  swelling  and  blue  coloration;  finally,  rais- 
ing of  the  epidermis  in  bullte.  The  epidermis  then 
separates  leaving  the  corium  exposed;  this  is  at  first 
greenish  yellow,  afterwards  blackish  brown  and 
leathery.  At  the  edge  of  the  gangrenous  part  the 
skin  becomes  inflamed,  and  by  the  formation  of  pus 
and  granulation  tissue  a  gutter-shaped,  often  circular 
space  is  gradually  formed — the  zone  of  demarcation. 
The  more  severe  the  injury  the  deeper  is  the  gangrene 
so  that  subcutaneous  tissue,  fascia  (Fig.  134),  muscles 
and  bone  may  become  necrosed  and  cast  off. 

After  separation  of  the  gangrenous  part  an  ulcer  is 
left,  called  decubital  ulcer,  which  is  covered  with 
slimy,  greenish-yellow  connective-tissue  shreds  and 
fetid  pus.  A  neglected  decubital  ulcer  may  give  rise 
to  extensive  putrid  inflammation  or  gaseous  phleg- 
mon, as  the  pus  always  contains  putrefactive  bacteria, 
especially  in  decubital  ulcer  over  the  sacrum  which  is 
infected  from  the  faeces.  Erysipelas  may  also  occur 
in  decubital  ulcer.  In  neglected  cases  the  gangrene 
may  also  extend  deeply  and  cause  extensive  destruc- 
tion. 

Pressure-necrosis  in  the  internal  organs  (larynx, 
esophagus,  intestine)  is  dangerous  from  perforating 
ulceration  or  hemorrhage;  also  from  stenosis  after 
healinor. 


'O 


Treatment.  Gangrene  of  the  skin  may,  in  many 
cases,  be  prevented,  or,  at  any  rate  limited,  by 
prophylactic  treatment.  Decubital  ulcers  (bedsores) 
may  be  prevented  by  applications  of  spirit  of  cam- 
phor to  the  skin  of  the  parts  exposed  to  pressure,  by 
air  cushions  and  frequently  changing  the  patient's 
position.  If  the  skin  is  discolored  an  ointment  dress- 
ing should  be  applied,  and  this  should  be  changed  if 

351 


the  patient  complains  of  pain.  As  the  pain  also 
subsides  in  a  few  days  under  continuous  pressure  of 
a  dressing,  its  removal  is  often  neglected,  and  then 
when  it  is  removed  there  may  be  gangrene  down  to 
the  bone.  In  emaciated  patients  the  bony  promi- 
nences should,  therefore,  be  well  padded,  and  the 
skin  disinfected  before  applying  the  dressing. 

If  gangrene  has  developed  the  skin  must  be  pro- 
tected against  infection  by  a  dressing.  Separation  of 
the  gangrenous  part  may  be  hastened  by  moist  dress- 
ings with  two  per  cent,  boric  acid  lotion,  three  per 
cent,  peroxide  lotion,  or  camphor  liniment,  applied 
several  times  daily.  Forcible  removal  of  the  gan- 
grenous parts  while  they  are  firmly  attached  is  not 
advisable;  they  should  be  removed  by  scissors  when 
almost  completely  loose.  The  ulcer  may  be  treated 
with  moist  dressings  or  ointments,  and  with  caustics 
when  granulations  have  sprung  up.  After  extensive 
gangrene  of  the  skin  the  space  may  be  closed 
by  undermining  the  skin  and  suturing;  or,  if  this 
is  impossible,  by  a  plastic  operation  by  means  of 
pedunculated  flaps. 

Fig.  134  shows  a  case  of  moist  gangrene  of  the 
skin  with  necrosis  of  the  abdominal  fascia.  Part  of 
the  skin  is  separated  from  the  healthy,  somewhat 
reddened  and  inflamed  skin  around  it,  by  a  zone  of 
demarcation.  The  gangrenous  part  is  still  firmly 
attached  to  the  subjacent  structures.  In  some  places 
the  skin  has  separated,  exposing  the  abdominal 
fascia,  the  yellowish  color  of  which  shows  that  it 
has  already  undergone  necrosis.  The  borders  of 
the  ulcer  were  undermined,  and  it  discharged  fetid 
pus. 

In  this  case  the  gangrene  was  caused  by  a  sub- 
cutaneous injection  of  salt  solution,  performed  on  a 
patient  in  a  state  of  collapse.  Gangrene  of  the  skin 
may  occur  after  injection  of  large  quantities  of  salt 
solution  when  the  injection  is  made  intracutaneously 


instead  of  subcutaneously;  also  when  the  fluid  is  too 
hot,  or  not  steriHzed. 

The  ulcer  became  clean  under  dressings  of  peroxide 
lotion;  the  gangrenous  skin  and  necrotic  fascia  sep- 
arated; the  edges  of  the  fascia  and  the  skin  were 
sutured  separately,  and  primary  union  took  place. 
As  sutures  in  fascia  often  do  not  hold,  the  patient 
was  ordered  an  abdominal  belt  to  prevent  abdominal 
hernia. 


353 


GANGRjENA  CARBOLICA  (Carbolic  gangrene) 
Plate  C\1I,  Fig.  135. 

In  tliis  case  carbolic  acid  dressings  were  applied 
to  a  wound  in  the  finger.  The  end  of  the  finger 
became  white  and  the  epidermis  was  destroyed  as 
far  as  the  carbolic  acid  dressing  extended,  exposing 
the  corium.  The  patient  had  no  feeling  in  the  tip 
of  the  finger  and  sufl^ered  from  severe  pain.  The  tip 
of  the  finger  gradually  became  black  and  shrunken 
(dry  gangrene). 

The  figure  shows  gangrene  of  the  terminal  pha- 
lanx. The  greenish-yellow  color  at  the  junction  of 
the  terminal  with  the  middle  phalanx  indicates  com- 
mencing gangrene.  In  the  middle  of  the  second 
phalanx  there  is  a  wide  zone  of  granulation  tissue  in- 
dicating the  line  of  demarcation.  Severe  pain  in  the 
finger  was  due  to  thrombosis  of  the  terminal  arteries 
caused  by  the  action  of  carbolic  acid.  Later  on 
there  was  loss  of  sensation  in  the  finger  from  paralysis 
of  the  sensory  nerves. 

Moist  dressings  were  applied,  and  in  a  few  weeks 
a  groove  of  demarcation  extended  down  to  the  bone. 
In  the  peripheral  part  gangrene  extended  to  the  fas- 
cia, muscles,  tendons  and  bone.  Healing  took  place 
after  disarticulation  at  the  interphalangeal  joint. 

It  must  be  borne  in  mind  that  even  one  per  cent, 
carbolic  lotion,  after  a  few  hours'  application  only, 
may  cause  gangrene  of  the  skin  and  deep  necrosis  by 
thrombosis  of  the  vessels.  Certain  individuals  ap- 
pear to  be  predisposed  to  gangrene  after  fomenta- 
tions with  carbolic  acid,  and  sometimes  lysol  or 
alcohol ;  especially  when  gutta  percha  tissue  is  placed 
over  them,  preventing  evaporation.  After  a  short 
application  the  skin  may  recover.  Acetic  acid  dress- 
ings hasten  recovery. 

354 


Bockenheiiner,  Alias. 


lab.  (A' I 


Fig.  135.    Oangraena  carbolica. 


Bockenheimer,  Atlas. 


Tab.  CVm. 


Fig.  136.     Combustio  entheniatnsa  -  bullosa  ~  escliarotica. 


Rcbman  Company,  Neve-York. 


COMBUSTIOERYTHEMATOSA-BULLOSA-ESCHAROTICA 

{Hums) 
Plate  CVin,  Fig.  136. 

Burns  may  be  caused  by  the  action  of  radiant  heat; 
e.g.  prolonged  exposure  to  hot  sun  or  a  hot  fire.  The 
heat  may  arise  from  solids,  liquids  or  gases.  Elec- 
tricity (lightning  stroke)  and  the  X-rays  may  also 
cause  burns;  also  strong  acids  and  alkalis  (sulphuric 
and  nitric  acids,  caustic  potash  and  soda). 

Burns  of  the  mucous  membrane  of  the  mouth, 
tongue,  pharynx,  esophagus  and  intestine  are  caused 
by  certain  chemicals  swallowed  as  poisons.  These 
may  cause  death  by  oedema  of  the  glottis,  or  later  on 
by  perforating  ulceration  of  the  gut  and  peritonitis. 
If  the  ulcers  heal,  they  lead  to  stenosis  of  the  gut. 

Burns  of  the  skin  may  be  caused  by  strong  caus- 
tics; such  as  trichloracetic  acid,  for  removal  of  warts; 
Vienna  paste,  tartar  emetic  ointment,  etc. 

Tender  skins  {e.g.  children)  react  to  slight  degrees 
of  heat;  e.g.  after  the  application  of  poultices, 
fomentations. 

The  mildest  degree  of  burn — also  called  the  first 
degree — consists  in  arterial  hyperaemia,  causing  red- 
ness and  slight  swelling:  of  the  skin.  There  is  more 
or  less  pain  or  tenderness,  itching  and  tension  of  the 
skin.  In  this  form  there  is  early  and  complete  resti- 
tution to  normal,  sometimes  after  desquamation  of 
the  epidermis. 

The  second  degree  of  burn  is  characterized  by  the 
formation  of  bulhe.  Besides  redness  caused  by  the 
first  degree,  the  epidermis  is  raised  in  blisters  by 
exudation  of  lymph  between  the  epidermis  and  the 
corium.  The  blisters  contain  yellowish  fluid  or 
gelatinous    masses,    and    may    develop    twenty-four 

355 


hours  after  the  injury.  In  severe  burns  of  the  second 
degree  some  of  the  blisters  rupture,  exposing  the  red 
corium,  which  is  very  painful  to  touch.  This  form 
of  burn  is  common  after  boiler  explosions,  gas  explo- 
sions, and  scalding  with  steam  or  hot  water.  Heal- 
ing by  epidermization  of  the  corium  takes  two  or 
three  weeks,  but  the  skin  is  restored  to  the  normal 
condition  without  scarring,  provided  the  process  has 
not  been  complicated  by  suppuration. 

In  the  third  degree  of  burn  the  epidermis  and 
corium  are  destroyed,  to  a  greater  or  less  extent 
according  to  the  severity  of  the  injury.  The  resulting 
gangrene  of  the  tissues  is  due  to  three  factors ;  loss  of 
water  from  the  tissues;  loss  of  blood  supply  from 
acute  thrombosis  of  the  vessels;  and  coagulation  of 
albumen  in  the  tissues.  The  skin  becomes  black 
and  gangrenous.  Sensation  is  lost  at  this  part;  but 
there  is  always  pain  due  to  burns  of  the  first  and 
second  degrees  in  the  surrounding  parts. 

In  severe  burns  the  fascia,  muscles  and  bones  may 
undergo  necrosis,  as  well  as  the  skin.  The  separa- 
tion of  the  necrosed  parts  takes  place  in  the  usual 
way  by  an  inflammatory  zone  of  demarcation. 
\  Burns  of  the  third  degree  are  liable  to  infection  of 

the  exposed  tissues  by  pyogenic  and  putrefactive 
bacteria,  so  that  the  wounds  take  months  to  heal, 
with  hypertrophic  scars  which  cause  contractures 
of  the  joints  and  form  adhesions  with  neighlioring 
parts.  The  scars  of  burns  of  the  third  degree  are 
easily  lacerated  and  may  give  rise  to  carcinoma  (Fig. 
20).  In  burns  of  the  third  degree  there  is  also  the 
danger  of  general  infection  from  prolonged  suppura- 
tion. These  cases  may  also  be  fatal  from  exhaustion, 
hemorrhage  from  erosion  of  vessels,  or  amyloid  dis- 
ease of  the  kidney,  liver,  etc. 

In  burns  of  the  fourth  degree  there  is  complete 
charring  of  all  the  tissues,  which  fall  to  ashes  when 
touched. 

It  is  obvious  that  the  effect  of  a  burn  on  the  organ- 

356 


ism  depends  on  the  degree  of  the  burn,  the  extent  of 
surface  involved,  the  part  of  the  body  affected,  and 
the  condition  of  the  patient  beforehand.  Burns  of 
the  first  and  second  degrees  when  they  are  not  very 
extensive  are  not  serious;  but  if  a  third  of  the  body 
is  affected,  even  in  burns  of  the  first  degree,  there  is 
fatal  constitutional  disturbance,  especially  in  chil- 
dren. Apart  from  the  severe  pain,  rapid  collapse 
sets  in.  The  skin  becomes  cold,  pale  and  covered 
with  sweat;  the  pulse  is  small  and  i-apid;  the  patient 
complains  of  thirst;  consciousness  is  retained  till 
death  occurs  in  two  or  three  days.  As  the  patients 
are  fully  conscious  and  in  good  spirits,  and  do  not 
complain  of  any  more  pain,  it  is  necessary  to  explain 
to  the  relatives  and  friends  that  death  after  extensive 
burns  is  almost  inevitable. 

In  these  severe  cases  the  temperature  is  subnormal. 
There  is  sometimes  delirium  and  coma.  In  extensive 
burns  of  the  second  degree,  complicated  by  general 
infection,  there  is  high  temperature,  delirium,  diar- 
rhea and  fetid  discharge  from  the  wounds.  Duodenal 
ulcer  may  also  occur.  Death  may  occur  from 
urjemic  coma  following  anuria.  The  autopsy  shows 
ecchymoses  and  thromboses  in  all  the  organs,  paren- 
chymatous nephritis,  etc. 

In  extensive  burns  death  may  be  caused  by  shock, 
which  may  be  due  to  great  pain,  sudden  cooling  of 
the  skin,  or  overheating  of  the  blood,  as  in  heat- 
stroke. Accumulation  of  poisonous  substances  in 
the  blood  may  also  cause  death. 

Burns  of  the  third  degree,  when  affecting  certain 
regions,  give  rise  to  various  disfigurements  and  con- 
tractures. The  eyelids  and  mouth  may  be  disfigured 
by  contracting  scars  (ectropion).  The  head  may  be 
flexed  on  the  thorax;  the  fingers  may  become 
united,  etc. 

Differential  Diagnosis.  Burns  may  be  con- 
founded with  frostbite,  in  the  absence  of  history. 

357 


Treatment.  In  burns  of  the  first  degree  the  sur- 
rounding healthy  skin  should  be  disinfected,  and 
ointment  applied  to  the  burnt  part.  In  burns  of  the 
second  degree  small  blisters  can  be  left  to  dry  up; 
large  blisters  should  be  opened  at  the  base,  the  lymph 
evacuated  and  the  epidermis  replaced.  The  loosened 
epidermis  then  generally  becomes  attached.  If  the 
blisters  are  already  broken,  the  loose  epidermis 
should  be  removed  and  the  exposed  corium  pow- 
dered with  rice  powder,  talc  or  flour.  Bismuth 
dressings  are  useful;  but  oil  and  lime  water  applica- 
tions should  not  be  employed,  as  they  favor  infection. 
Antiseptic  gauze  is  to  be  avoided,  on  account  of  the 
danger  of  poisoning. 

Morphia  may  be  required  if  there  is  much  pain, 
especially  when  the  dressings  are  changed.  The 
latter  should  be  covered  with  plenty  of  wool. 

The  more  infection  of  the  surface  is  prevented  by 
careful  treatment,  the  less  is  the  scar  tissue.  If 
there  is  much  scar  tissue  this  may  be  excised  and 
the  wound  covered  by  skin  flaps.  Injection  of  ten 
per  cent,  thiosinamin  solution  may  be  tried  to  absorb 
scar  tissue. 

In  the  extremities,  resection  of  joints,  amputation 
or  disarticulation  may  be  necessary  when  the  limbs 
are  useless,  or  the  seat  of  exhausting  suppuration,  or 
when  there  is  threatening  general  infection.  Such 
operations  should  not  be  performed  till  the  patient 
has  somewhat  recovered  from  shock.  Burns  of  the 
neck  and  mouth  may  require  tracheotomy.  In  exten- 
sive burns  of  the  second  and  third  degrees  with  much 
discharge  permanent  baths  are  useful. 

In  all  severe  burns  the  general  condition  of  the 
patient  requires  attention.  To  support  the  heart, 
digitalis,  camphor  injections,  subcutaneous  injections 
of  salt  solution  may  be  indicated.  The  whole  body 
must  be  well  protected  by  wool.  The  function  of  the 
kidneys  should  be  stimulated  by  diuretics  (caffein, 
acetate  of  potash,  etc.). 

358 


Burns  caused  by  acids  require  neutralization  by 
the  application  of  alkalis  [^e.g.  soap);  while  burns 
caused  by  alkalis  require  neutralization  by  weak 
acids  (acetic  acid,  vinegar).  Internal  burns  caused 
by  swallowing  chemicals  may  require  special  surgical 
treatment  for  the  resulting  stenosis. 

In  lightning-stroke  treatment  is  generally  useless. 
In  heat-stroke  and  sunstroke,  the  overheated  body 
must  be  cooled  by  applying  ice  bags  to  the  head  and 
over  the  heart,  and  by  drinking  large  quantities  of 
water. 

Fig.  136  shows  all  four  degrees  of  burns.  In  this 
case  the  injury  was  caused  by  red-hot  metal.  The 
first  degree  is  shown  by  reddening  of  the  epidermis; 
the  second  degree  by  the  formation  of  blisters  con- 
taining yellow  fluid;  the  third  degree  (on  the  back 
of  the  hand)  by  the  destruction  of  epidermis,  exposing 
the  corium,  and  in  some  places  the  bones;  the  fourth 
degree  by  charring  of  the  ends  of  the  second  and  fifth 
fingers.  The  first  phalanges  of  these  fingers  also 
show  burns  of  the  third  degree.  The  different 
degrees  of  burn  are  due  to  the  differences  in  the 
length  of  time  during  which  the  heat  was  acting  in 
the  different  places.  The  second  and  fifth  fingers 
were  disarticulated;  the  rest  of  the  hand  recovered, 
with  moderate  function,  after  treatment  by  the  per- 
manent water  bath. 


359 


COWGELATIO  ERYTHEMATOSA— BULLOSA  (Frostbite) 
Plate  CIX,  Fig.  137 

Extreme  degrees  of  cold  may  cause  destruction  of 
the  tissues,  in  the  same  way  as  burns.  Here  again, 
the  extent  of  injury  depends  on  the  degree  of  cold, 
the  duration  of  its  action,  and  the  condition  of  the 
patient.  Dry  cold  is  better  borne  than  moist  cold. 
Certain  individuals  are  especially  liable  to  the  effects 
of  cold — persons  in  a  state  of  alcoholic  intoxication, 
angemic  individuals,  children  and  old  people,  cooks 
and  others  who  are  exposed  to  rapid  changes  of  tem- 
perature. Frostbite  may  be  caused  by  the  action  of 
snow,  ice  or  liquid  air. 

Pernio  or  chilblain  may  be  regarded  as  a  chronic 
form  of  frostbite,  affecting  the  fingers,  toes  and 
ears.  It  is  especially  common  in  chlorotic  indi- 
viduals and  causes  swelling  and  blueness  of  the  skin 
with  numerous  bluish-red  nodules.  These  often 
cause  unbearable  itching  and  burning  sensations, 
and,  when  scratched,  give  rise  to  intractable  ulcers. 

Acute  frostbite  appears  in  different  degrees  accord- 
ing to  the  degree  of  cold,  in  the  same  way  as  burns. 
The  parts  of  the  body  usually  affected  are  the  fingers, 
ears,  nose  and  toes.  In  the  first  degree  of  frostbite 
there  is  redness  of  the  skin  from  hypersemia  (erji;he- 
matous  congelation).  This  is  usually  followed  in  a 
short  time  by  the  formation  of  a  blister.  The  red- 
ness increases  when  the  patient  comes  into  a  warm 
room,  or  takes  alcoholic  drinks.  It  is  accompanied 
by  burning  and  itching  pains,  which  may  continue 
for  a  long  time.  The  redness  may  even  last  for  life 
after  a  single  frostbite  of  the  first  degree;  for  instance 
in  the  nose  of  a  chlorotic  woman.     In  most  cases  of 

360 


Bockenlieinier,  Atlas. 


Tab.  CI.X. 


Fig.  137.    Congelatio  eiytliemato,sa  —  bullosa. 


Rfbman  Company,  N'ew-York. 


frostbite  of  the  first  degree,  however,  there  is  com- 
plete recovery. 

Longer  exposure  to  cold,  or  exposure  to  more 
severe  cold,  causes  venous  congestion,  cedema,  and 
the  formation  of  blisters.  The  skin  becomes  blue  or 
white,  cold  and  insensitive,  and  is  often  covered  with 
numerous  blisters,  with  bluish-black  contents;  after 
their  rupture  the  exposed  corium  is  dark  in  color  and 
very  painful.  Infection  is  liable  to  occur,  causing 
extensive  ulceration  with  little  tendency  to  heal,  and 
leading  to  cicatricial  contraction.  Pain  is  more  severe 
and  continuous  in  frostbite  of  the  second  degree. 

In  frostbite  of  the  third  degree,  in  the  same  way  as 
in  burns  of  the  third  degree,  there  is  gangrene  of  the 
skin  and  necrosis  of  the  deeper  tissues,  due  to  throm- 
bosis of  the  vessels.  The  skin  is  at  first  bluish  black, 
cold  and  insensitive,  later  on  quite  black.  Separa- 
tion of  the  frozen  tissues  may  take  place  either  by  dry 
or  moist  gangrene.  The  zone  of  demarcation  has 
often  a  putrid  character.  Progressive  phlegmonous 
inflammation  may  spread  from  the  borders  of  the 
frozen  area,  and  may  lead  to  general  infection. 
Along  with  frostbite  of  the  third  degree  the  neighbor- 
ing parts  are  affected  in  the  first  and  second  degrees, 
and  other  parts  are  ulcerated;  so  that  the  clinical 
picture  is  variegated.  The  gangrenous  and  necrotic 
parts,  after  some  months,  are  cast  off  spontaneously. 
The  nails  soon  fall  off  in  frostbite  of  the  hand.  In 
frostbite  of  the  third  degree,  parts  which  at  first 
showed  signs  of  the  second  degree  only,  may  after- 
wards become  gangrenous. 

Healing  eventually  takes  place  by  the  formation  of 
very  unsightly  hypertrophic  scars,  which  may  cause 
contractures.  Contractures  may  also  be  caused  by 
paralysis  of  nerves,  or  by  waxy  degeneration  of  muscle 
fibres.  Frostbite  is  said  to  cause  changes  in  the 
blood-vessels  which  may  lead  to  secondary  gangrene. 
The  general  condition  of  the  patient  is  little  impaired 
in    acute   local   frostbite    of   circumscribed   regions. 

361 


The  period  of  healing  varies  according  to  the  degree 
of  the  frostbite,  but  is  usually  longer  than  in  burns 
and  causes  more  severe  after  effects. 

General  frostbite  is  common  in  severe  winters 
among  weary  wayfarers  who  weaken  their  power  of 
resistance  to  cold  by  alcoholic  drinks.  After  the  pre- 
liminary feeling  of  cold  they  become  overcome  by 
fatigue,  fall  down  and  become  frostbitten.  People 
may  even  fall  unconscious  without  any  previous 
symptoms.  The  body,  lying  on  the  ground,  becomes 
cooled  to  below  20°  C.  (68°  F.).  Exposed  parts  may 
even  become  frostbitten  by  slight  degrees  of  cold, 
acting  continuously  on  the  recumbent  body.  The 
nose,  ears  and  hands  then  become  frozen  to  ice  and 
fall  off  when  touched,  while  the  blood  becomes 
decomposed  and  contains  ice  crystals.  This  condi- 
tion may  last  for  days  before  death  takes  place.  Only 
early  attempts  at  resuscitation  can  do  any  good  in 
these  cases.  The  heart  is,  however,  so  weakened 
that,  even  if  the  patients  recover  consciousness,  they 
succumb  some  days  later  with  delirium,  coma  and 
heart  failure.  The  prolonged  action  of  intense  cold 
may  freeze  not  only  the  external  parts  of  the  body 
but  may  convert  all  the  fluid  parts  to  ice.  The 
expansion  caused  by  the  conversion  of  liquids  to  ice 
then  ruptures  the  surface  of  the  body. 

Patients  who  have  been  exposed  to  general  frost- 
bite must  not  be  suddenly  warmed,  as  this  may  cause 
death  from  shock.  The  stronger  the  patient's  con- 
stitution the  better  is  the  chance  of  recovery ;  but  the 
prognosis  of  general  frostbite  is  very  unfavorable. 
Extensive  paralysis  (hemiplegia  and  paraplegia)  may 
remain  after  recovery  from  the  immediate  effects, 
and  the  patients  may  suffer  for  years  from  headache, 
pains  in  the  joints,  and  a  tendency  to  local  frostbite 
due  to  changes  in  the  arteries.  [These  secondary 
phenomena  may  be  due  to  frostbite  acting  as  an 
exciting  cause  on  pre-existing  latent  disease,  espe- 
cially disease  of  the  arteries. 

362 


Differential  Diagnosis.  Frostbite  may  be  mis- 
taken for  burns  in  the  absence  of  any  history. 

Treatment.  Chilblains  may  be  treated  by  hot 
air  apparatus  or  hot  sandbaths,  together  with  general 
treatment  of  chlorosis  by  iron  and  arsenic.  The 
irritation  may  be  relieved  by  painting  with  tincture 
of  iodine,  balsam  of  Peru,  or  by  inunction  with 
bromocoU  ointment.  Ulcers  are  best  treated  with 
Hehra's  diachylon  ointment.  Recurrence  can  be 
limited  by  prophylactic  measures. 

In  acute  local  frostbite  the  parts  must  be  warmed 
gradually — by  rubbing  with  snow  or  cold  applica- 
tions. Early  treatment  in  this  way  may  restore  the 
frozen  skin.  In  frostbite  of  the  second  degree,  large 
blisters  should  be  opened  and  broken  blisters  re- 
moved. Ulcers  should  be  treated  with  strict  asepsis, 
and  dressed  with  sterile  gauze  or  ointment.  The 
extremities  should  be  suspended  on  splints,  avoiding 
all  pressure. 

In  cases  with  moist  gangrene  and  putrefactive 
phlegmonous  inflammation,  early  amputation  is  often 
necessary  to  prevent  general  infection.  In  dry  gan- 
grene, amputation  may  be  deferred  till  a  zone  of 
demarcation  has  formed.  Plastic  operations  are 
often  required  after  spontaneous  separation  of  gan- 
grenous parts  of  the  fingers  or  toes.  IMorphia  injec- 
tions may  be  necessary  for  the  severe  pain  in  the 
early  stages  of  frostbite.  Paralysis  may  be  improved 
by  electricity,  and  contractures  by  massage;  but  the 
latter  more  often  require  a  secondary  operation. 

In  general  frostbite  the  body  must  be  very  grad- 
ually warmed.  The  patient  is  placed  in  a  cool  room 
and  rubbed  down  with  cold  water.  He  is  then  put 
in  a  tepid  bath  the  temperature  of  which  is  gradually 
raised  in  the  course  of  several  hours.  If  respiration 
has  stopped,  artificial  respiration  must  be  performed. 
Injections  of  camphor  and  subcutaneous  infusion  of 
salt  solution  is  useful  to  stimulate  the  action  of  the 

363 


heart.  When  the  patient  recovers  consciousness  hot 
alcoholic  drinks  should  be  given.  Local  gangrene 
resulting  from  general  frostbite  is  identical  with  that 
occurring  in  severe  local  frostbite,  and  requires  the 
same  treatment. 

Fig.  137  shows  a  case  of  frostbite  of  the  first  and 
second  degrees  in  a  workman  who  had  had  repeated 
milder  attacks  in  the  winter,  after  exposure  of  his 
hands  to  cold  water  during  his  work.  The  hands 
were  permanently  blue,  and  in  the  winter  painful 
chilblains  developed  on  the  fingers,  especially  on  the 
extensor  surface.  He  finally  developed  frostbite  of 
the  second  degree,  which  is  shown  by  the  whiteness 
of  the  ends  of  the  fingers,  and  other  changes  in  the 
fourth  finger.  The  skin  over  the  first  joint  of  the 
fourth  finger  is  blue,  and  a  large  blister  containing 
yellow  lymph  has  developed  on  the  extensor  surface 
of  the  last  joint.  The  patient  complained  of  severe 
burning  pains  in  the  tips  of  the  fingers,  especially  in 
the  fourth.  The  blister  was  opened  and  the  epider- 
mis replaced  on  the  corium,  the  hand  was  dressed  with 
ointment  and  put  on  a  splint.  Under  this  treatment 
the  skin  ouickly  recovei'ed. 


364 


Bockenlieinier,  Atlas. 


Tab.  ex. 


Fig.  138.     Combuslio  (X-Rays). 


Rebman  Company,  New-York. 


X-Ray  Bum 

Plate  CX,  Fig.  138. 

The  X-rays  have  been  used  for  the  treatment  of 
various  diseases;  sometimes  with  good  results,  as  in 
lupus,  chronic  eczema,  etc.;  sometimes  with  no 
result,  as  in  malignant  tumors.  A  single  exposure, 
properly  performed,  causes  no  injury  to  the  skin; 
but  repeated  exposures  sometimes  give  rise  to  changes 
in  the  skin,  especially  when  the  tubes  are  placed 
nearer  than  thirty  centimeters  from  the  skin,  and 
when  the  exposures  are  too  long  or  too  frequent. 
The  changes  produced  take  the  form  of  a  dermatitis, 
and  certain  individuals  appear  to  be  predisposed 
to  it. 

The  first  signs  are  redness,  swelling  and  tension 
of  the  skin,  accompanied  by  itching  and  burning 
sensations.  This  condition  is  followed  by  fissures 
in  the  skin  and  finally  ulceration,  which  is  character- 
ized by  its  chronic  and  progressive  nature.  Workers 
in  X-ray  laboratories  are  subject  to  a  chronic  form 
of  dermatitis  of  the  hands,  unless  they  protect  them- 
selves with  gloves,  lead-foil,  etc.  The  skin  becomes 
dr}%  cracked  and  fissured;  the  nails  become  brittle 
and  are  often  shed.  Some  cases  become  gangrenous, 
and  the  necrotic  tissue  is  separated  by  a  zone  of 
demarcation.  Other  cases  develop  into  carcinoma 
and  require  amputation  of  the  hand.  Some  cases 
are  fatal  from  exhaustion. 

X-ray  dermatitis  can  be  prevented  by  placing  the 
tube  not  less  than  thirty  centimeters  from  the  skin, 
and  by  avoiding  too  long  or  too  frequent  exposures. 

365 


Workers  in  X-ray  laboratories  should  take  all  possible 
precautions,  by  the  use  of  lead-foil,  gloves,  etc.  The 
mode  of  action  of  the  rays  is  still  not  quite  clear. 
Cases  have  been  observed  in  which  exposure  to  X- 
ray  has  caused  atrophy  of  the  testicles,  interruption 
of  pregnancy,  etc. 

Treatment.  In  mild  cases,  due  to  the  action 
of  a  single  exposure  on  a  sensitive  skin,  the  action 
of  sea  air  is  said  to  be  beneficial.  Chronic  X-ray 
dermatitis  is  very  rebellious  to  all  the  usual  form  of 
treatment. 

Fig.  138  shows  an  X-ray  burn  which  followed  a 
long  exposure  made  for  a  swelling  of  the  thigh.  The 
skin  became  red,  then  white,  and  finally  ulcerated 
in  several  places.  The  brown  coloration  indicates 
healing  of  the  less-affected  parts.  The  ulcers  healed 
after  the  application  of  simple  dusting  powder. 

This  case  is  interesting  because  the  X-rays,  which 
were  applied  to  a  peripheral  sarcoma  of  the  femur, 
not  only  caused  no  improvement  but  aggravated  the 
tumor.  This  shows  the  danger  of  the  treatment  of 
malignant  tumors  by  the  X-rays,  for,  as  operative 
treatment  is  postponed,  more  extensive  operation 
becomes  necessary  later  on.  In  this  case  X-ray 
examination  showed  the  presence  of  sarcomatous 
masses  in  the  soft  parts  (by  bony  spicules)  necessi- 
tating high  amputation  through  the  thigh. 


366 


F^)Ockeiilicimer,  Atla?. 


Tab.  CXI. 


Fig.  139.    Alal  perlorant  du  jiied    -  Qangraena  Ra\iiaud. 


Rebman  f'mnpany,  Ncvr-Yoik. 


MALUM   PERFORANS  PEDIS  (Perforating  Ulcer  of  the  Foot) 
GANGR^NA   RAYNAUD   (Raynaud:i  gangrene) 
Plate  CXI,  Fig.   139. 

Perforating  ulcer  of  the  foot  commences  as  a  hard 
horny  thickening  of  the  epidermis  over  the  heads  of 
the  third  and  fifth  metatarsal  bones,  somewhat  re- 
sembHng  a  clavus  but  much  more  extensive.  The 
epidermis  becomes  fissured  and  finally  ulcerated  in 
the  center.  The  ulcer  is  characterized  by  its  ten- 
dency to  extend  deeply,  and  by  its  persistence  in  spite 
of  all  kinds  of  treatment.  The  disease  is  essentially 
chronic  and  leads  to  destruction  of  muscles,  tendon- 
sheaths,  bones  and  joints,  by  continuous  crateriform 
extension  of  the  ulcer  into  the  deeper  tissues.  The 
epidermis  always  remains  thickened  at  the  border  of 
the  ulcer,  and  is  sometimes  undermined.  The  visible 
surface  of  the  ulcer  is  small  and  is  covered  with 
flabby  granulation  tissue.  Necrotic  shreds  often  pro- 
trude, indicating  extensive  necrosis  of  the  fascia  and 
tendons.  There  is  often  loss  of  sensation  in  the  skin 
for  some  distance  round  the  ulcer.  As  a  rule  there  is 
little  pain,  but  sometimes  parsesthesia.  The  general 
health  may  suffer  from  prolonged  suppuration,  or  the 
condition  may  be  aggravated  by  acute  progressive 
phlegmonous  inflammation. 

Perforating  ulcer  is  of  trophoneurotic  origin  and 
due  to  disease  of  the  nervous  system.  It  occurs  in 
tabes,  sjTingomyelia,  certain  forms  of  spina  bifida 
(Figs.  143  and  144),  and  also  in  diseases  where  sen- 
sation is  lost  in  the  lower  extremities.  Owing  to  the 
loss  of  sensation  the  patient  does  not  notice  the 
injury  to  the  sole  of  the  foot  caused  by  pressure,  and 
in  this  way  a  trophoneurotic  ulcer  develops,  charac- 

367 


terized  by  hard  borders  due  to  the  horny  epidermis 
which  is  normally  present  in  the  sole  of  the  foot. 
These  ulcers  may  also  develop  on  the  outer  border 
of  the  foot  in  cases  of  paralytic  pes  varus  (Fig.  143). 
Some  authors  attribute  the  condition  to  disease  of  the 
blood-vessels  (arteriosclerosis,  endarteritis  obliterans) 
as  well  as  to  trophoneurotic  disorder,  and  in  many 
cases  both  conditions  are  probably  present.  That 
the  blood-vessels  play  a  part  in  the  pathology  of  per- 
forating ulcer  is  supported  by  the  fact  that  this  con- 
dition is  often  met  with  in  syphilitics  and  alcoholics 
with  vascular  disease. 

Raynaud's  gangrene — which  is  better  called  local 
asphyxia,  as  it  only  consists  in  the  first  stage  of  gan- 
grene— is  usually  symmetrical,  and  affects  the  feet 
more  often  than  the  hands.  After  a  short  premon- 
itory stage  during  which  the  digits  become  cold 
and  white  (vaso-motor  constriction),  the  tips  of  the 
fingers  or  toes  become  dark-purple  and  the  proxi- 
mal parts  red  (vaso-motor  paralysis).  The  disease  is 
due  to  vaso-motor  disturbance  depending  on  disease 
of  the  peripheral  or  central  nervous  systems.  The 
symptoms  consist  in  parsesthesias  and  disturbance 
in  the  temperature  sense,  and  pain  on  changes  of 
temperature. 

Differential  Diagnosis.  A  commencing  per- 
forating ulcer  may  be  mistaken  for  a  clavus  compli- 
cated by  a  mucous  bursa  and  central  fistula;  but  the 
latter  does  not  extend  so  deeply. 

Raynaud's  disease  may  be  confounded  with  the 
early  stages  of  other  forms  of  gangrene  (Figs.  132, 
133  and  140),  or  frostbite;  but  the  changes  in  Ray- 
naud's disease  are  diffuse  and  symmetrical. 

Treatment.  Even  in  the  early  stage  of  perforat- 
ing ulcer,  removal  of  the  callosity  and  necrosed  tissue 
gives  little  result.  In  the  later  stages  no  treatment  is 
of  any  use.     The  wound  must  be  protected  from 

368 


infection  by  aseptic  dressings.  In  some  cases  partial 
amputation  of  the  foot  is  necessary,  especially  when 
there  is  extensive  necrosis  of  the  plantar  fascia 
{Lisfranc's,  Choparfs  or  Pirogojfs  amputations).  If 
there  is  phlegmonous  inflammation  free  incisions 
must  be  made  down  to  the  bone.  Amputation 
through  the  leg  may  be  necessary  in  cases  of  pro- 
gressive phlegmon  or  general  infection.  Internally 
iodide  of  potassium  should  be  administered,  and 
other  treatment  for  arteriosclerosis  (Fig.  140). 

In  Raynaud's  disease  exposure  to  cold  must  be 
avoided.  Treatment  by  hot  air,  hot  sand-baths  and 
massage  is  useful. 

Fig.  139  shows  a  case  of  perforating  ulcer  of  the 
foot  in  a  typical  position,  over  the  head  of  the  third 
metatarsal  bone.  The  epidermis  is  fissured  and 
thickened  round  the  small  ulcer,  which  is  covered 
with  granulations.  A  piece  of  necrosed  fascia  is 
seen  protruding  from  the  ulcer.  The  peripheral  part 
of  the  foot  shows  diffuse  bluish-red  coloration,  which 
was  also  present  symmetrically  on  the  other  foot 
(Raynaud's  disease).  The  ulcer  showed  no  tendency 
to  heal  under  treatment  by  aseptic  dressings  and  rest 
in  bed,  so  amputation  was  performed  at  the  tarso- 
metatarsal joint. 


369 


GANGRiENA  DIABETICA   (Diabetic  gangrene) 
ARTERIOSCLEROSIS 

Plate  CXII,  Fig.  140. 

Diabetes  mellitus  greatly  diminishes  the  power  of 
resistance  of  the  body  against  infection.  Various 
pyogenic  affections,  such  as  furuncle,  carbuncle, 
abscesses  (e.g.  mammary  abscess,  Plate  V)  or  exten- 
sive phlegmons  may  develop  in  diabetic  patients  after 
comparatively  slight  causes,  especially  in  the  lower 
extremities.  The  dry,  irritable  skin  of  diabetics  is 
liable  to  infection  through  scratches.  Moreover,  the 
sugai'-containing  tissues  are  favorable  to  the  growth 
of  bacteria,  which  are  thus  able  to  cause  progressive 
phlegmonous  inflammation.  Putrefactive  phlegmon 
is  more  common  than  pyogenic  phlegmon  in  diabetics, 
and  gives  rise  to  moist  gangrene  of  the  skin,  necrosis  of 
the  deeper  tissues,  and  often  general  infection.  Dry 
gangrene  may  also  develop  suddenly  in  the  lower 
extremities  in  diabetics  affected  with  arteriosclerosis. 
In  this  way,  the  whole  leg  may  be  affected  with  dry 
gangrene  from  thrombosis  of  the  popliteal  artery. 
The  first  symptoms  are  pain,  numbness  and  tingling 
sensations  in  the  toes.  One  or  more  toes  then  become 
bluish  black  and  cold,  later  on  bluish  gray  (Fig.  140) ; 
while  the  skin  on  the  dorsum  of  the  foot  is  red  and 
oedematous.  In  this  stage  there  are  often  severe 
neuralgic  pains,  while  the  general  condition  of  the 
patient  is  impaired  by  increase  of  sugar  in  the  urine, 
sleeplessness,  headache  and  exhaustion.  In  old 
diabetics  with  dry  gangrene  of  the  toes  demarcation 
may  take  several  months  to  develop.  Dry  gangrene 
may  always  change  to  moist,  the  latter  progressing 
more  rapidly. 

370 


Bockenheimer,  Atlas. 


Tab.  CXII. 


Fig.  140.    Gangraena  diabetica  ^  Artcriosl<lerosis. 


Rcbman  Company,  New-York. 


The  prognosis  in  these  cases  is  bad,  especially 
when  there  is  much  sugar  in  the  urine.  Death  may 
occur  from  heart  failure,  general  infection  or  diabetic 
coma.  A\Tien  the  general  treatment  of  diabetes  fails 
to  act,  the  gangrene  usually  extends,  and  leads  to 
death. 

Prophylaxis  consists  in  the  early  diagnosis  and 
treatment  of  diabetes.  It  is,  therefore,  important 
to  examine  the  urine  for  sugar  in  all  cases  of  pyogenic 
and  putrefactive  infections.  Diabetic  patients  should 
pay  strict  attention  to  bodily  cleanliness  and  try  to 
avoid  all  kinds  of  infection.  They  should  also  avoid 
the  causes  which  lead  to  arteriosclerosis. 

Differential  Diagnosis.  Diabetic  gangrene  is 
distinguished  from  other  forms  of  gangrene  by  exam- 
ination of  the  urine.  Extensive  calcification  of  the 
arteries  can  sometimes  be  seen  by  X-ray  examination. 

Treatment.  In  dry  gangrene  it  is  best  to  wait 
for  demarcation,  unless  extensive  arteriosclerosis  is 
present.  If,  however,  the  popliteal  artery  is  pulse- 
less, amputation  of  the  leg  is  the  only  remedy.  If 
there  is  no  arteriosclerosis  the  gangrene  may  slowly 
extend  for  months.  When  demarcation  is  complete 
amputation  may  be  performed  directly  above  the  line 
of  demarcation.  Before  demarcation  the  parts  should 
be  treated  with  dry  aseptic  dressings  (moist  dressings 
cause  putrefaction),  and  be  suspended.  In  slowly 
extending  moist  gangrene  demarcation  may  be  waited 
for  if  the  temperature  does  not  remain  high.  In  rap- 
idly extending  moist  gangrene  with  high  temperature 
early  amputation  is  indicated  some  distance  above  the 
gangrene.  In  gangrene  of  the  lower  extremity  with 
arteriosclerosis  it  is  better  to  amputate  through  the 
thigh;  for  the  flaps  after  amputation  through  the  leg 
are  badly  nourished  even  in  healthy  individuals,  and 
in  diabetics  they  are  liable  to  become  gangrenous. 
Amputation  through  the  thigh  is  best  performed  above 

371 


the  condyles  (supracondylar  amputation),  or  through 
the  epiphyseal  line.  Epiphyseal  stumps  have  con- 
siderable supporting  power.  As  a  rule,  amputation 
may  be  conservative  in  slowly  progressing  cases  which 
are  not  complicated  by  phlegmonous  inflammation, 
arteriosclerosis  or  high  temperature.  On  the  other 
hand,  rapidly  extending  gangrene  complicated  by 
arteriosclerosis  and  phlegmon  always  requires  high 
amputation. 

It  is  best  to  give  an  injection  of  scopomorphine 
{Riedel's  preparation)  before  the  operation ;  less  quan- 
tities of  chloroform  or  ether  are  then  required.  In 
these  cases  both  general  anaesthesia  and  lumbar 
anaesthesia  are  badly  borne,  and  infiltration  anaesthe- 
sia is  contra-indicated,  as  it  causes  inflammation  of 
the  weakened  tissues.  When  the  vessels  are  afl'ected 
with  arteriosclerosis  they  should  be  compressed  by  the 
fingers  of  assistants  during  the  operation,  as  the  appli- 
cation of  the  elastic  tourniquet  may  cause  thrombosis. 
The  wound  should  be  dressed  with  sterile  gauze; 
iodoform  is  contra-indicated  on  account  of  the  danger 
of  iodoform  poisoning.  Primary  suture  of  the  flaps 
should  not  be  attempted,  and  these  should,  therefore, 
be  made  larger  than  usual.  Secondary  suture  of  the 
flaps  may  be  performed  after  a  few  days  if  the  pro- 
gress of  the  case  is  satisfactory.  Ligatures  must  not 
be  applied  too  tightly  to  vessels  affected  with  arterio- 
sclerosis, as  the  coats  of  the  vessel  may  give  way  and 
cause  secondary  hemorrhage.  The  operation  must 
be  performed  under  the  strictest  aseptic  precautions, 
as  the  diabetic  tissues  are  easily  infected,  and  osteo- 
myelitis may  occur  in  the  bone  stump  or  phlegmonous 
inflammation  in  the  soft  parts. 

After  the  wound  has  healed  ulceration  is  common 
in  the  amputation  stump.  This  must  be  treated  with 
aseptic  dressings  to  avoid  fresh  phlegmonous  inflam- 
mation. In  some  cases  amputation  of  both  legs  may 
be  necessary  for  gangrene  of  both  the  feet.  Only 
about  fifty  per  cent,  of  cases  of  diabetic  gangrene 

372 


recover  after  amputation,  a  great  many  cases  suc- 
cumbing to  diabetic  coma.  Wlienever  possible  the 
iimount  of  sugar  should,  therefore,  be  reduced  by 
general  treatment  of  the  diabetes  before  operation. 
Cases  where  acetone  is  present,  and  which  give  a 
positive  result  with  the  perchloride  of  iron  reaction, 
have  an  unfavorable  prognosis.  The  general  con- 
dition requires  treatment  by  strict  diet  and  the  admin- 
istration of  salicylate  or  bicarbonate  of  soda  in  large 
doses.  Subcutaneous  injection  of  saline  solution  may 
be  tried  in  diabetic  coma.  Thirst  may  be  relieved  by 
tincture  of  opium  or  by  von  Bergmamis  diabetic 
drink  (citric  acid  10;  glycerin,  100;  distilled  water, 
1.000). 


373 


ARTERIOSCLEROSIS   (Atheroma) 

This  disease  consists  in  the  thickening  of  the  walls 
of  the  vessels  by  connective  tissue  formation,  with  sub- 
sefjuent  fatty  degeneration  of  the  inner  and  middle 
coats  (atheroma)  and  the  deposition  of  calcareous 
plates,  causing  roughening  of  the  inner  surface  of 
the  vessel  and  leading  to  thrombosis.  The  disease 
is  more  common  in  the  male  sex.  Central  and 
peripheral  nervous  affections,  especially  those  causing 
vaso-motor  disturbances ;  infective  diseases,  including 
typhoid,  malaria,  syphilis,  general  infection,  leprosy, 
cout  and  diabetes;  the  action  of  alcohol,  nicotin  and 
lead;  overexertion  and  sudden  exposure  to  cold  have 
all  been  cited  as  causes  of  arteriosclerosis.  [The 
term  arteriosclerosis  is  here  used  to  describe  what  is 
generally  known  in  England  as  atheroma.  The  fun- 
damental cause  of  this  is  generally  considered  to  be 
syphilis,  though  other  causes  mentioned  above  proba- 
bly contribute.  General  arteriosclerosis,  character- 
ized by  a  general  fibroid  thickening  of  all  the  arteries, 
is  of  more  complex  etiology,  the  chief  factors  being 
probably  syphilis,  chronic  alcoholism,  infective  fevers, 
gout,  and  microbial  toxaemias]. 

A  tortuous  condition  of  the  temporal  and  radial 
arteries  is  ofteia  present  in  arteriosclerosis,  along  with 
differences  in  the  pulse  in  different  arteries.  Exten- 
sive calcification  is  sometimes  visible  by  X-ray  exam- 
ination. 

The  symptoms  begin  with  pains  of  a  rheumatic 
character.  The  feet,  in  which  the  disease  often  be- 
gins, are  blue,  cold  and  dry.  Sensations  of  numb- 
ness and  tingling  are  often  present.  There  may  be 
severe  pain  in  the  heels,  preventing  the  patient  from 

374 


walking  {Charcot's  intermittent  claudication).  Ex- 
tensive arteriosclerosis  may  cause  gangrene  of  the 
lower  extremities.  In  women  arteriosclerosis  more 
often  affects  the  hands  causing  great  pain  and  loss  of 
function;  but  gangrene  in  the  hands  is  very  rare. 
Arteriosclerosis  of  the  cerebral  arteries  causes  severe 
headaches,  attacks  of  loss  of  consciousness,  or  cerebral 
hemorrhage. 


-'to^ 


Differential  Diagnosis.  Commencing  arterio- 
sclerosis of  the  extremities  with  no  visible  change  in 
the  vessels  may  be  mistaken  for  gout  or  rheumatism, 
etc.  In  advanced  cases  the  diagnosis  is  easy,  owing 
to  the  hardness  of  the  vessels. 

Treatment.  Prophylactic  treatment  consists  in 
avoiding,  as  far  as  possible,  the  causes  which  may 
lead  to  arteriosclerosis.  The  best  therapeutic  meas- 
ures are  those  which  promote  metabolism  and 
strengthen  the  heart;  for  instance,  light  gymnastics, 
massage,  mud  baths,  sand  baths,  ^Yiesbaden  hot 
springs,  etc.  Internally  iodide  of  potassium  should 
be  administered.  Hot  air  treatment  and  hot  potash 
baths  are  useful  for  the  pains  in  the  heel.  In  severe 
cases  morphia  may  be  necessary. 

Fig.  140  shows  commencing  gangrene  of  the  right 
foot  in  a  man  of  fifty-six,  suffering  from  diabetes  for 
some  years.  The  toes  are  bluish  red  in  some  parts, 
grayish  black  in  others,  while  the  dorsum  of  the  foot 
is  red.  The  skin  was  pale  and  cold.  The  discolora- 
tion appeared  in  the  course  of  a  few  hours,  and  in  a 
few  days  extended  to  the  ankle  joint.  jNIoist  gangrene 
spread  rapidly  from  the  toes,  and  lymphangitis 
extended  up  the  leg. 

The  X-rays  showed  numerous  calcareous  deposits 
in  the  anterior  and  posterior  tibial  arteries.  Ampu- 
tation was  performed  above  the  knee  joint,  after  the 
sugar  had  been  reduced  from  five  to  two  per  cent,  by 

375 


three  days'  treatment  of  the  diabetes.  After  opera- 
tion the  sugar  diminished  still  further,  and  the  tem- 
perature fell — two  favorable  signs.  Secondary  suture 
of  the  stump  was  performed  on  the  fifth  day  and  the 
wound  healed  in  four  weeks.  After  general  treat- 
ment of  the  diabetes  the  sugar  disappeared  from  the 
urine. 

The  figure  also  shows  other  changes.  On  the 
inner  side  of  the  foot  over  the  metatarsophalangeal 
joint  is  a  large  clavus,  and  another  on  the  fifth  toe. 
The  nail  of  the  great  toe  is  affected  with  onychogry- 
posis,  a  common  condition  in  old  people  who  neglect 
their  feet.  As  the  nail  caused  trouble  in  walking,  it 
was  removed  under  local  anaesthesia. 


376 


y 


L^eiilieiiner,  Alias. 


Tab.  CXI II 


Fie.  141.    Arthritis  urica. 


Rcbnian  Company,  Ncw■^■olk. 


ARTHRITIS  URIC  A   (Gout;/ Arthritis) 
Plate  CXIII,  Fig.  141. 

Gout  is  a  disorder  of  metabolism  which  is  often 
transmitted  from  father  to  son  for  generations.  It 
therefore  usually  occurs  among  people  with  a  hered- 
itary predisposition.  It  most  often  affects  middle- 
aged  men  who  indulge  in  high  living  and  who  take 
too  little  exercise. 

The  disease  is  due  to  the  deposit  of  urate  of  soda 
in  various  places,  especially  in  the  cartilages  of  the 
joints.  According  to  Pfeiffer  there  is  no  increase  in 
the  formation  of  urate  of  soda,  but  only  deficient 
elimination.  The  urate  of  soda  deposits  form  yel- 
lowish-white masses  in  the  cartilage,  synovial  mem- 
brane, tendons,  subcutaneous  and  periarticular  tis- 
sue, bursse,  bronchi,  intestinal  mucous  membrane 
and  kidneys — in  fact,  in  all  the  tissues  and  organs  of 
the  body.  An  acute  attack  of  gout  is  caused  by 
deposit  of  urate  of  soda  in  a  joint,  usually  the  meta- 
tarso-phalangeal  joint  of  the  great  toe  (Podagra). 
The  symptoms  are  great  pain  in  the  affected  joint, 
slight  rise  of  temperature  and  a  certain  amount  of 
constitutional  disturbance  (gastric  pain,  nervous  phe- 
nomena, rheumatic  pains,  etc.).  The  first  attack  is 
sometimes  excited  by  an  injury  to  the  foot.  The 
region  of  the  joint  is  swollen  and  oedematous,  and 
the  skin  shows  erysipelatous  reddening  and  phleg- 
monous infiltration.  The  slightest  touch  or  move- 
ment causes  intense  pain.  There  is  slight  effusion 
in  the  joint.  After  some  hours  the  pain  subsides,  but 
senerallv  recurs  on  the  second  night;  and  so  on  for 
about  two  weeks,  till  the  attacks  gradually  become 
less  painful  and  finally  disappear.     Slight  swelling  of 


the  affected  joint  remains.  Later  on  fresh  attacks 
may  occur,  often  after  many  years.  During  the 
attacks  there  is  always  a  heavy  sediment  in  the  urine. 
Repeated  attacks  may  give  rise  to  a  permanent  nodu- 
lar swelling  of  the  joint,  and  slight  trauma  may  bring 
on  another  acute  attack  {e.g.  hand  pressure  on  gouty 
fingers). 

Chronic  gout,  which  is  rarely  primary  and  generally 
results  from  the  acute  form,  is  observed  also  among 
the  poorer  classes.  It  often  affects  the  joints,  but  is 
less  painful.  The  frequency  with  which  the  meta- 
tarso-phalangeal  joint  is  attacked  is  perhaps  due  to 
bad  circulation  of  the  blood,  owing  to  its  peripheral 
position.  This  joint  is  also  affected  by  arthritis 
deformans  in  old  people.  Large  deposits  of  urate  of 
soda  give  rise  to  gouty  nodules  or  tophi,  which  occur 
in  the  joints  of  the  fingers,  hand,  foot  and  elbow. 
They  also  occur  in  the  cartilages  of  the  ear,  nose  and 
eyelids  in  the  form  of  small,  yellowish  nodules,  which 
become  hard  and  painful.  In  advanced  cases  of 
gout  these  nodules  may  be  found  in  all  the  joints  and 
cartilages,  joint  capsules,  tendon-sheaths,  cartilages 
of  the  ribs,  and  in  other  tissues. 

Microscopic  examination  of  gouty  deposits  shows 
the  presence  of  crystals  of  urate  of  soda.  These  crys- 
tals act  on  the  tissues  like  foreign  bodies,  and  cause 
not  only  pain  but  gradual  necrosis  by  pressure.  The 
necrosed  tissues  are  expelled  by  the  formation  of  fis- 
tulas, and  through  the  latter  infection  of  the  joints 
may  take  place.  Joint  infection  may  also  occur  by 
way  of  the  blood  (staphylococcal  or  streptococcal  in- 
fection), without  communication  with  the  exterior. 
Suppuration  in  a  gouty  joint  is  always  serious,  as  it 
easily  leads  to  general  infection.  The  cartilages  of 
the  joint  may  be  destroyed  by  the  gouty  deposits, 
without  the  occurrence  of  suppuration,  and  lead  to 
subluxation  and  anchylosis.  Tophi,  especially  when 
situated  in  the  subcutaneous  tissue,  may  give  rise  to 
ulceration,  venous  thrombosis  and   phlebitis,  espe- 

378 


cially  in  the  lower  extremities.  Eczema  of  the  skin  is 
common  in  gouty  subjects. 

Although  in  most  cases  of  gout  the  joints  are 
affected,  and  the  symptoms  are  those  of  joint  inflam- 
mation, gouty  deposits  in  other  tissues  and  organs 
may  give  rise  to  the  most  diverse  symptoms.  Depos- 
its in  the  tendo  Achillis  causes  achylodynia  with  pain 
in  the  heel;  deposits  in  other  places  may  cause 
sciatica  and  lumbago,  asthma  and  bronchitis,  iritis 
and  other  affections  of  the  eye,  disorders  of  the  intes- 
tine, etc. 

In  all  long-standing  cases  of  gout  there  is  a  danger 
of  complications  affecting  the  internal  organs.  The 
chief  of  these  is  chronic  interstitial  nephritis,  in  which 
numerous  deposits  of  urate  of  soda  are  found  in  the 
kidneys,  which  may  give  rise  to  renal  calculus. 
Gouty  subjects  are  also  liable  to  emphysema  of  the 
lungs.  The  prognosis  in  cases  of  pronounced  gout 
is  always  doubtful. 

Differential  Diagnosis.  Gouty  arthritis  is  most 
often  confounded  with  chronic  rheumatism,  but  in 
the  latter  the  skin  over  the  joints  is  unchanged.  In 
purulent  arthritis  there  is  high  temperature  and  rigors 
while  the  temperature  in  gout  does  not  exceed  38°  C. 
(100°  F.)  provided  no  suppuration  is  present.  En- 
chondromas  of  the  fingers  (Fig.  50)  differ  from  gouty 
deposits  by  the  absence  of  pain.  Gout  of  other 
organs  must  be  diagnosed  by  the  history  of  the  case. 
Large  deposits  of  urate  of  soda  can  be  seen  by  X-ray 
examination;   e.g.  in  bursae. 

Treatment.  Persons  who  are  predisposed  to 
gout  should  try  to  avoid  it  by  careful  living,  exercise, 
etc.  In  acute  gout,  tincture  of  colchicum  should  be 
given  in  large  doses  (fifty  to  one  hundred  drops  daily). 
The  affected  joint  should  be  wrapped  in  wool  and 
suspended  on  a  splint.  Hot  air  treatment  is  also 
useful.     If  suppuration  occurs  in  the  joint  (with  high 

379 


temperature  and  rigors)  artlirotomy  must  be  per- 
formed under  strict  aseptic  precautions.  In  some 
cases  resection  of  the  joint  may  be  necessary.  Gen- 
eral infection  is  common  in  such  cases. 

During  the  acute  attack  the  patient  should  avoid 
meat,  eggs  and  alcohol,  and  drink  plenty  of  alkaline 
waters.     Purgatives  are  also  indicated. 

Ice  bags  and  moist  fomentations  should  be  avoided, 
as  the  former  may  cause  necrosis  of  the  skin  and  the 
latter  maceration.  Massage  is  contra-indicated.  In- 
ternally, ten  to  twenty  drops  of  hydrochloric  acid  may 
be  given  daily;  salicylate  of  soda,  aspirin  and  iodide 
of  potassium  are  also  useful.  Phenacetin  may  be 
given  for  the  pains,  or  morphia  in  severe  cases. 

When  there  are  frequent  attacks  of  gout  treatment 
at  the  various  springs  is  useful  (Wiesbaden,  Karlsbad, 
etc.).  The  diet  should  be  carefully  regulated — 
plenty  of  vegetables,  especially  celery;  little  carbo- 
hydrates, little  meat,  little  alcohol  and  no  beer. 

Fig.  104  shows  a  case  of  acute  gouty  arthritis 
affecting  the  metacarpo-phalangeal  joint  of  the  second 
finger.  The  whole  joint  is  swollen  and  very  painful 
to  touch  and  on  movement.  Tophi  are  present  on 
the  other  metacarpo-phalangeal  joints  and  on  the 
interphalangeal  joints  of  the  second  to  the  fifth 
fingers.  The  skin  over  the  tophi  is  white  from  pres- 
sure. The  patient,  whose  grandfather  was  gouty, 
had  suffered  for  years  from  gouty  arthritis  in  the 
joints  of  both  hands. 


380 


Malformations 


ENCEPHALOCELE  OCCIPITALIS   (Occipital  Encephahcele) 
RHACHISCHISIS 

Plate  CXIV,  Fig.  142. 
MYELOCELE— PES  VARUS 

Plate  CXV,  Fig.  143. 
MYELOCYSTOCELE— MYXOLIPOMA 

Plate  CXVl,  Fig.  144. 
LYMPHANGIOMA    (Congenital  multiple) 

Plate  CXM,  Fig.  145. 
TERATOMA  MOROGERMINALE  (Monogerminal  Teratoma) 

Plate  CXMI,  Fig.  146. 
DUCTUS  OMPHALO-MESENTERICUS  PERSISTENS 

(PersiMcttt  omphalo-mesenteric  duct) 

Plate  CXVIII.  Fig.  147. 
HERNIA  FUNICULI  UMBILICALIS  CONGENITA 

(Congenital  Umbilical  Hernia) 

Plate  CXVIII,  Fig.  148. 
AMPUTATIONES  AMNIOTICS   (Amniotic  Amputations) 

Plate  CXIX,  Fig.  149. 
AKROMEGALLA   (Acromegaly) 
MAKROMELLA 
MAKROGLOSSLA 

Plate  CXX,  Fig.  150. 

The  study  of  malformations  (teratology)  is  of  great 
interest  to  the  surgeon,  because  many  of  these  can  be 
improved  by  surgical  intervention.  A  knowledge  of 
embryology  is  necessary  in  order  to  understand  mal- 
formations. We  distinguish  between  primary  mal- 
formations which  affect  the  embryo  in  its  early 
stages  of  development,  and  secondary  malformations 
which  affect  a  part  already  formed,  by  some  influence 
actins  on  it  during  intra-uteriiie  life.  The  latter  are 
spoken  of  as  arrested  development.  Slight  disturb- 
ances in  development  are  called  anomalies;  greater 
deformities,   malformations.     The  greater  the  mal- 

381 


formation,  the  earlier  was  its  origin.  The  causes 
which  lead  to  malformation  may  be  already  present 
in  the  embryo,  or  arrested  development  may  be  due 
to  external  causes.  Experimental  observations  on 
animals  have  shown  that  malformations  may  be 
caused  by  injury.  In  the  lower  extremities  malfor- 
mations may  be  caused  by  pressure  or  by  abnormal 
positions  of  the  fetus  in  the  uterus  (various  forms  of 
talipes — pes  varus,  pes  valgus,  pes  calcaneus).  Pres- 
sure on  the  fetus  may  be  caused  by  a  uterine  tumor 
or  by  deficiency  in  the  liquor  amnii,  and  signs  of  such 
pressure  can  often  be  seen  after  birth  of  the  child. 
Many  malformations  are  due  to  anomalies  in  the 
membranes;  e.g.  amniotic  adhesions.  All  malfor- 
mations caused  in  this  way  are  cases  of  arrested 
development.  These  amniotic  adhesions  or  bands 
may  prevent  the  union  of  parts  which  should  nor- 
mally become  united  (branchial  clefts)  or  may  cause 
duplication  of  parts,  or  partial  or  complete  separa- 
tion (amniotic  amputations,  aberrant  glands). 


382 


Bockenheimer,  Atlas. 


Tab.  CXIV. 


Fig.  142.    Encephalocele  occipitalis  —  Rachischisis. 


Rfbman  Company,  New- York. 


ENCEPHALOCELE  OCCIPITALIS    {Occimtal  EncenhaloceU) 
RHACHISCHISIS 

Plate  CXIV    Fig.  142. 

Encephalocele,  or  cephalocele,  is  a  malformation 
due  to  arrested  development,  and  occurs  in  two 
regions — the  region  of  the  nose  (syncipital  en- 
cephalocele) and  the  occipital  region  (occipital 
encephalocele).  The  former  is  subdivided  into  naso- 
ethmoidal, uaso-frontal  and  naso-orbital;  the  latter 
into  superior  and  inferior  occipital  encephalocele,  ac- 
cording as  it  is  situated  above  or  below  the  occipital 
protuberance.  According  to  Miiller,  one  case  of  en- 
cephalocele occurs  in  thirty-six  hundred  births.  The 
deformity  is  due  to  more  or  less  extensive  deficiency 
in  the  closure  of  the  cerebro-spinal  canal,  caused  by 
trauma  or  by  amniotic  bands.  The  earlier  this 
occurs  in  fetal  life  the  more  extensive  is  the  cleft  in 
the  cerebro-spinal  canal.  In  extensive  cases  there 
may  be  acrania  or  anencephalus,  while  in  slighter 
degrees  there  is  only  a  defect  in  the  bone  and  dura 
mater.  Owing  to  the  defect  in  the  dura  mater  there 
may  be  prolapse  of  the  brain  through  the  bone,  gen- 
erally a  hernial  protrusion  of  one  of  the  ventricles. 
According  to  von  Berc/ma?in  the  existence  of  a  true 
congenital  meningocele  in  which  the  dura  is  intact, 
and  there  is  only  a  hernial  protrusion  of  the  mem- 
branes through  the  gap  in  the  bone,  must  be  regarded 
as  doubtful.  The  author's  observations  on  myelo- 
cele (Fig.  134)  have  also  shown  that  the  inner  cover- 
ing of  the  protrusion,  which  is  said  to  be  dura,  often 
consists  of  connective  tissue  only,  and  that  the  inner 
wall  is  often  formed  of  ciliated  columnar  epithelium, 
and,  therefore,  represents  the  degenerated  ventricle 

383 


of  the  brain.  Hence  the  so-called  meningocele  is  a 
true  encephalocele  or  myelocystocele  (Fig.  144). 

As  the  subdivision  of  the  different  forms  into 
meningoceles,  encephaloceles,  encephalomeningoceles 
encephalocystoceles  and  encephalocysto-meningo- 
celes  depends  on  pathological  anatomy,  and  cannot 
be  distinguished  clinically,  it  is  sufficient  for  all  prac- 
tical purposes  to  use  the  term  encephalocele  or  ceph- 
alocele  for  all  hernial  protrusions  through  the  skull, 
especially  as  they  mostly  contain  a  protrusion  of  the 
ventricle.  For  instance,  the  so-called  encephalo- 
meningocele  has  been  shown  to  be  not  a  true  menin- 
gocele, but  a  cystic  formation  which  has  become 
gradually  cut  off  from  a  primary  hernia  cerebri  or 
encephalocele. 

Cephaloceles  occurring  at  the  sagittal  suture,  the 
fontanelles  or  other  parts  of  the  skull  are,  according 
to  von  Bergmann,  either  dermoids  or  caused  by 
trauma  after  birth  (spurious  traumatic  acquired 
cephalocele) .  Congenital  cephaloceles  are  either  syn- 
cipital  or  occipital.  Syncipital  cephaloceles  have  gen- 
erally a  wide  base,  while  occipital  cephaloceles  are 
pedunculated.  Occipital  cephaloceles  may  attain  a 
large  size — as  large  as  the  child's  head.  The  skin 
at  the  base  of  the  tumor  is  thickened  and  covered 
with  radially  arranged  hair.  The  tumor  may  be  cov- 
ered with  normal  skin,  but  more  commonly  most  of 
the  surface  resembles  fresh  scar  tissue;  or,  when 
ulceration  is  present,  it  resembles  the  mucous  mem- 
brane of  the  intestine.  Vascular  anomalies — telan- 
giectases and  angiomas — are  often  present.  The 
tumor  is  diminished  by  pressure,  and  can  be  com- 
pletely emptied  in  cases  when  it  apparently  con- 
sisted of  a  collection  of  fluid  only.  After  the  tumor 
has  been  emptied  by  pressure  the  hole  in  the  skull 
can  be  felt,  situated  symmetrically  in  the  middle  line. 
It  is  generally  small  and  circular,  and  can  sometimes 
be  shown  by  X-ray  examination.  As  the  tumor  can 
be  diminished  by  external  pressure,  so  is  it  increased 

384 


by  internal  pressure;  e.g.  when  the  child  cries. 
Cystic  cephaloceles  may  be  translucent.  In  other 
eases  there  is  little  diminution  on  pressure.  Irregular 
partitions  can  then  be  felt  in  the  interior  of  the  sac. 
Firm  pressure  then  usually  causes  bulging  of  the 
fontanelle,  or  sometimes  convulsions.  Sometimes 
pulsation  is  observed  in  cephaloceles.  The  skull  in 
these  cases  is  generally  very  small,  and  often  flat- 
tened. Other  malformations  are  often  present.  The 
infants  are  weakly  and  have  a  subnormal  tempera- 
ture. The  prognosis  is  generally  unfavorable,  but 
is  better  in  cases  where  the  cephalocele  can  be  com- 
pletely emptied  of  fluid  by  pressure,  and  when  no 
brain  substance  can  be  felt  in  the  sac  after  evacuation 
of  the  fluid.  Cases  of  occipital  cephalocele  with  a 
large  gap  in  the  bone,  often  extending  to  the  vertebrae 
of  the  neck,  and  protrusion  of  both  occipital  lobes 
and  the  whole  of  the  cerebellum,  are  soon  fatal. 

Differential  Diagnosis.  Syncipital  cephalocele 
may  be  mistaken  for  dermoid  or  lipoma.  Diagnosis 
depends  on  the  presence  of  a  gap  in  the  bone,  diminu- 
tion of  the  tumor  on  pressure  and  the  presence  of 
other  deformities.  Occipital  cephalocele  may  be 
mistaken  for  cephalhematoma,  which  sometimes 
occurs  on  the  occipital  bone,  especially  as  cephal- 
hematoma may  be  surrounded  by  a  hard  ring  at  its 
base  caused  by  the  raised  periosteum.  Cephalhema- 
toma is  not  diminished  by  pressure.  However,  di- 
minution by  pressure  may  be  absent  in  cephalocele  if 
the  gap  in  the  bone  is  occluded.  In  doubtful  cases 
an  operation  will  settle  the  diagnosis. 

Treatment.  Puncture  and  injection  is  useless 
and  dangerous  in  cephalocele.  The  only  rational 
treatment  is  a  radical  operation.  The  sac  is  exposed 
by  incision  through  the  skin,  separated  down  to  the 
bone,  ligatured  and  removed.  The  defect  in  the  bone 
may  be  covered  in  by  suturing  the  periosteum  over 

385 


it,  by  a  pedunculated  bone  flap,  or  by  a  celluloid 
plate.  In  cases  where  brain  substance  is  present  in 
the  sac,  the  operation  can  only  be  performed  when 
the  brain  substance  can  be  reduced  through  the  gap 
in  the  bone  without  producing  symptoms  of  cerebral 
compression.  Removal  of  portions  of  brain  still 
possessed  of  function  may  cause  dangerous  symp- 
toms, but  a  functionless  dropsical  protrusion  may  be 
removed  without  danger.  Cases  of  large  defect  in 
the  skull,  with  defect  in  the  cervical  vertebrae,  or  cases 
combined  with  other  extensive  malformations,  are 
inoperable.  The  after-treatment  is  complicated  by 
the  escape  of  cerebro-spinal  fluid,  which  is  always 
abundant,  even  after  the  most  careful  closure  of  the 
bone  defect.  The  dressings  therefore  require  chang- 
ing several  times  daily  to  prevent  infection  of  the 
wound. 

Fig.  142  shows  a  cephalocele  situated  symmetri- 
cally in  the  middle  line  under  the  occipital  protuber- 
ance. The  skin  at  the  base  of  the  tumor  was  thick- 
ened ;  over  the  greater  part  of  the  surface  it  resembled 
fresh  scar  tissue,  and  presented  numerous  fine  rami- 
fying vessels.  The  tumor  could  be  completely 
emptied  of  its  fluid  contents  by  pressure,  without 
causing  symptoms  of  cerebral  pressure.  After  this 
a  circular  hole  in  the  bone  could  be  felt  about  one- 
half  centimeter  in  diameter.  This  cephalocele  could 
have  been  completely  removed  by  radical  operation, 
but  for  the  presence  of  another  malformation  of  the 
spine  which  made  the  condition  of  the  infant  hopeless. 

In  the  dorso-lumbar  region  from  the  twelfth  dorsal 
to  the  third  lumbar  vertebra  is  a  condition  known  as 
rhachischisis  (spina  bifida).  This  is  a  condition  of 
arrested  development  of  the  spine  in  which  there  is 
absence  of  closure  of  the  embryonic  medullary  canal 
affecting  the  bones,  soft  parts,  spinal  cord  and  mem- 
branes. This  malformation  may  extend  the  whole 
length  of  the  spine,  and  is  then  known  as  total  pos- 

386 


terior  rhachischisis;    or  it  may   be   limited   to   one 
portion  only. 

Rhachischisis  represents  the  most  extreme  degree 
of  spina  bifida  (Figs.  143  and  144).  It  is  most  com- 
mon in  the  himbo-sacral  region,  because  the  medul- 
lary groove  closes  last  in  this  region  to  form  the 
neural  canal.  Rhachischisis  is  usually  associated 
with  other  extensive  malformations  such  as  anen- 
cephalus,  acrania,  absence  of  vertebral  bodies,  etc. 
Three  typical  zones  can  be  distinguished  situated 
symmetrically  on  each  side  of  the  vertebral  column: 
(1)  a  circular,  peripheral  zone  of  thickened  skin, 
often  covered  with  abundant  hair;  (2)  a  middle  zone 
which  resembles  fresh  cutaneous  scar  tissue,  or  the 
serous  coat  of  the  intestine,  and  has  hence  been  called 
the  epithelio-serous  zone;  a  central  zone  of  flabby 
granulations  with  a  depression  at  the  upper  and 
lower  ends,  which  represents  the  open  and  exposed 
spinal  cord.  The  depressions  at  each  end  of  the 
central  zone  lead  to  the  central  canal  of  the  spinal 
cord.  In  cases  where  the  spinal  cord  is  much 
exposed,  death  soon  occurs  from  meningitis. 


387 


Spina  Bifida 

MYELOCELE— PEDES  VARI 
Plate  CXV,  Fig.  U3. 

MYELOCYSTOCELE— MYXOLIPOMA 
Plate  CXVL,  Fig.  Hi. 

As  already  mentioned,  rhachischisis  represents  the 
most  extreme  degree  of  spina  bifida.  If  the  arrest 
of  development  is  limited  to  one,  two  or  three  verte- 
bral arches,  the  cleft  spinal  cord  is  not  exposed  in  the 
vertebral  groove  as  in  rhachischisis,  but  projects  in 
the  form  of  a  tumor  through  the  small  cleft  in  the 
vertebrae,  owing  to  pressure  of  fluid  on  its  ventral 
surface.  It  thus  forms  a  symmetrical  tumor  in  the 
middle  line,  with  the  same  three  characteristic  zones 
as  in  rhachischitis,  and  is  known  as  a  myelocele 
(Fig.  143). 

There  are  four  kinds  of  spina  bifida,  differing  in 
degree  according  to  the  date  of  their  appearance  in 
embryonic  life.  The  first  and  most  extensive  form 
is  rhachischisis,  which  has  already  been  mentioned. 
The  second  form  (myelocele)  appears  later  and  is 
limited  to  a  smaller  extent  of  the  spine,  although  it 
may  include  the  soft  parts,  bones  and  spinal  cord; 
this  forms  a  tumor-like  swelling.  The  third  form 
{myelocystocele)  occurs  still  later  in  embryonic  life,  at 
a  time  when  the  spinal  cord  and  the  skin  have  already 
closed  on  the  dorsal  surface  of  the  embryo,  but  the 
dura  mater  and  bone  have  not  yet  united.  The 
fourth  form  [meningocele)  only  occurs  in  the  lumbo 
sacral  region  where  the  spinal  cord  has  become  the 
filum  terminale.     Spina   bifida   occulta,   which   also 

388 


Bockenheimer,  Atlas. 


Tab.  CXV. 


Fig.  143.    Myelocele  -   Pedes  vari. 


Rebman  Company,  New- York. 


occurs  at  the  lower  extremity  of  the  vertebral  column, 
is  not  to  be  regarded  as  a  special  form,  but  as  a  men- 
ingocele. 

The  subdivision  of  spina  bifida  into  the  three  chief 
forms — myelocele,  myelocystocele  and  meningocele 
— is  the  most  suitable  for  practical  purposes.  Spina 
bifida  is  a  comparatively  rare  malformation,  occur- 
ring in  one  or  one  and  five-tenths  out  of  one  thousand 
infants. 

1.  Myelocele.  By  far  the  most  common  form  is 
myelocele.  According  to  von  Recklinghausen  this 
occurs  before  the  twelfth  day  of  embryonic  life,  as 
after  this  time  the  medullary  groove  closes  to  form 
the  neural  canal.  The  arrest  of  development  con- 
cerns the  dorsal  part  of  the  spinal  cord  and  mem- 
branes, the  vertebral  arches,  the  muscles  and  the 
skin.  A  tumor-like  swelling  is  then  formed  by  the 
formation  of  hydrops  on  the  ventral  side  of  the  spinal 
cord  which  continually  pushes  the  cord  out  of  the 
vertebral  canal  through  the  preformed  cleft.  Ac- 
cording to  von  Bergmann  the  occurrence  of  hydrops 
is  due  to  the  absence  of  dura  mater. 

Myelocele  forms  a  characteristic  swelling  with  a 
wide  base,  situated  symmetrically  in  the  middle  line, 
with  the  three  zones  already  mentioned  in  the  case 
of  rhachischisis;  viz.  an  outer  zone  of  thickened 
skin  with  abundant  hair,  and  often  telangiectases;  a 
second  zone  of  a  pink  color  resembling  new  scar 
tissue,  with  a  deep  network  of  ramifying  vessels;  a 
third  zone  of  an  oval  form  at  the  summit  of  the 
swelling,  red  and  tumid  like  intestinal  mucous  mem- 
brane, very  vascular,  and  covered  with  pus  a  few 
days  after  birth.  This  third  or  central  zone  repre- 
sents the  remains  of  the  cleft  spinal  cord,  and  is  called 
the  vasculo-medullary  zone  in  distinction  to  the 
epithelio-serous  or  second  zone.  At  the  upper  and 
lower  ends  of  the  third  zone  is  a  depression  through 
which  a  probe  can  be  passed  into  the  central  canal  of 
the   spinal   cord.     These   cases  generally   die   from 

389 


meningitis  through  infection  of  the  vasculo-medul- 
lary  zone.  Operative  treatment  is  useless.  The 
spinal  nerves  become  dragged  upon  by  the  formation 
of  the  protruding  myelocele,  causing  motor  paralysis 
of  the  lower  extremities,  bladder  and  rectum  (paraly- 
sis of  the  upper  extremities  when  the  myelocele  is 
situated  in  the  upper  part  of  the  spine). 

The  common  occurrence  of  pes  varus  in  these  cases 
(Fig.  143)  is  due  to  the  myelocele  being  usually 
situated  at  the  junction  of  the  lumbar  vertebrae  with 
the  sacrum  where  the  nerves  arise  which  supply  the 
anterior  and  posterior  tibial  muscles;  viz.  the  fourth 
and  fifth  lumbar  and  the  first  and  second  sacral 
nerves.  Sensory  disorders  are  rare  in  myelocele,  but 
trophoneurotic  disorders  occur  in  the  form  of  exten- 
sive eczema  and  decubital  ulcers,  especially  on  the 
feet;   in  pes  varus  on  the  outer  border  of  the  foot. 

Diagnosis  is  easily  made  by  the  characteristic  ap- 
pearance, the  presence  of  fluctuation  and  the  cleft  in 
the  bone.  There  is  no  diminution  in  the  swelling  by 
pressure  owing  to  the  absence  of  communication  with 
the  subarachnoid  space.  Myelocele  is  most  common 
in  the  lumbo-sacral  region;  after  this  in  the  cervical 
and  thoracic.  It  is  often  associated  with  other  mal- 
formations, such  as  umbilical  hernia,  etc.,  and  the 
infants  seldom  survive. 

2.  Myelocystocele.  This  form  consists  in  arrested 
development  of  the  vertebral  arches  and  dura  mater. 
It  appears  in  the  third  week  of  embryonic  life,  at  a 
time  when  the  medullary  groove  has  closed  to  form 
the  neural  tube,  and  the  epiblast  has  grown  over  it. 
Hydrops  of  the  central  canal  causes  bulging  of  the 
posterior  part  of  the  spinal  cord  through  the  gap  in 
the  vertebral  arches,  giving  rise  to  a  tumor-like  swell- 
ing of  the  spinal  cord  covered  by  the  soft  parts.  The 
substance  of  the  spinal  cord  soon  undergoes  degen- 
eration and  can  only  be  identified  by  the  presence  of 
ciliated  cylindrical  epithelium  on  the  inner  surface 
of  the  cavity  (the  remains  of  the  ciliated  epithelium 

390 


of  the  central  canal  of  the  spinal  cord).  In  the 
external  coverings  of  myelocystocele  there  is  often 
lipoma,  myxoma,  lymphangioma  or  teratoma.  The 
tumor  has  a  wide  base  and  is  covered  with  normal 
skin,  which  is  thickened  at  the  base  of  the  tumor. 
Sometimes  small  depressions  are  present  in  the  skin 
caused  by  the  remains  of  amniotic  bands  (Fig.  144). 
The  tumor  is  of  soft  consistence,  and  fluctuation  is 
always  present.  The  fluid  contents  of  the  tumor 
can  be  completely  reduced  by  pressure,  as  there  is 
direct  communication  with  the  central  canal,  and  also 
with  the  subarachnoid  space.  By  pressing  on  the 
tumor  the  transmission  of  fluid  pressure  can  be  felt 
at  the  fontanelle. 

Myelocystocele  is  often  combined  with  hydroceph- 
alus. Paralyses  are  rare,  as  the  motor  nerves  are 
not  displaced  by  the  malformation ;  at  the  most  there 
may  be  pes  varus  or  valgus  on  one  side,  due  to  the 
tumor  being  situated  unsymmetrically  more  to  one 
side  of  the  middle  line,  and  thus  dragging  on  a  motor 
nerve.  However,  extensive  myelocystocele  of  the 
lumbo-sacral  region  may  cause  paralysis  of  the 
bladder  and  rectum.  Trophoneurotic  disorders  are 
common.  Sometimes  paralysis  occurs  at  a  later  age, 
the  tumor  increasing  gradually  in  size  and  dragging 
on  the  spinal  cord  and  nerves.  Defective  bone  for- 
mation is  often  associated  with  myelocystocele — 
absence  of  vertebral  bodies,  unilateral  defects  in  the 
vertebral  laminae,  absence  of  ribs  or  patella,  sco- 
liosis, etc. 

3.  Meningocele,  x^ccording  to  recent  observations 
meningocele  can  only  occur  in  places  where  the  spinal 
cord  is  absent  (von  Bergmann).  In  this  condition 
there  is  defective  formation  of  the  vertebrae  and  dura 
mater,  so  that  the  pia  mater  protrudes  posteriorly, 
inclosing  the  filum  terminale.  In  this  way  a  pedun- 
culated swelling  is  formed,  covered  by  normal  skin, 
which  may  attain  the  size  of  a  child's  head  as  the 
amount  of  cerebro-spinal  fluid  in  the  sac  increases. 

391 


Paralysis  only  occurs  when  the  meningocele  is  large, 
and  is  then  generally  of  limited  extent.  There  is 
sometimes  abundant  hair  on  the  summit  of  the  swell- 
ing. Fluctuation  is  always  present,  but  there  is  only 
slight  diminution  on  pressure.  The  space  in  the  bone 
is  generally  smaller  than  in  myelocele.  Meningocele 
occurs  most  often  in  the  sacral  region. 

Spina  Bifida  Occulta,  according  to  the  most 
recent  observations,  is  a  form  of  meningocele  which 
becomes  ruptured  and  undergoes  spontaneous  heal- 
ing under  the  skin.  The  pressure  of  the  cicatrix  may 
cause  disturbances  which  are  not  noticed  till  the 
child  grows  older. 


to" 


Differential  Diagnosis.  Myelocele,  when  the 
vasculo-medullary  zone  is  very  extensive,  may  some- 
times be  mistaken  for  cavernoma.  In  rare  cases 
where  epidermization  of  the  second  zone  leads  to 
cicatrization  of  the  third  zone,  myelocele  may  be  mis- 
taken for  a  myelocystocele  in  which  the  skin  has 
become  cicatrized  after  ulceration.  In  such  cases 
diminution  of  the  tumor  on  pressure  points  to  myelo- 
cystocele. In  lipoma,  lymphangioma  and  teratoma 
there  is  no  diminution  in  the  tumor  on  pressure  unless 
there  is  a  myelocystocele  underneath  it ;  which,  how- 
ever, is  often  the  case.  Meningocele  may  be  mis- 
taken for  myelocystocele  when  it  is  not  situated  in 
the  sacral  region  (where  the  spinal  cord  is  absent). 
It  may  also  be  mistaken  for  sacral  tumors,  dermoids 
and  teratomata. 

The  prognosis  is  not  unfavorable  in  myelocystocele 
and  meningocele  provided  other  malformations  are 
absent  and  the  infant  has  a  strong  constitution. 

Treatment.  In  myelocele  a  radical  operation  is 
useless,  because  by  removal  of  the  cystic  sac  the 
spinal  cord  is  divided  and  unites  with  the  cicatrix. 
Reduction  of  the  infected  vasculo-medullary  zone  by 
operation    always    leads    to    meningitis.     Palliative 

393 


treatment,  by  puncture  of  the  sac,  is  all  that  can  be 
done  in  these  cases. 

Myelocystocele,  owing  to  its  covering  of  intact  skin, 
is  more  suitable  for  operation.  In  this  case  the 
operation  is  similar  to  that  for  hernia.  The  sac,  con- 
sisting of  degenerated  spinal  cord,  is  exposed  by  an 
incision  through  the  skin,  dissected  down  to  the  bone, 
ligatured  and  removed.  The  cleft  in  the  bone  is 
repaired  by  a  plastic  operation.  The  sac  is  often 
covered  by  a  fatty  tumor  which  also  requires  removal. 
Removal  of  the  sac  after  ligature  is  not  dangerous  in 
these  cases,  as  it  consists  only  of  functionless  degen- 
erated spinal  cord.  Meningitis  sometimes  follows 
these  operations,  but  most  cases  recover  and  may 
grow  up. 

Meningocele  offers  the  best  chances  for  operation. 
The  sac  is  opened  and  the  nerves  replaced  in  the  ver- 
tebral canal.  The  sac  is  then  ligatured  and  removed 
and  the  space  in  the  bone  closed  by  suture  of  the  soft 
parts,  or  by  bone  grafting.  The  prognosis  is  good 
after  these  operations. 

In  spina  bifida  occulta  with  disturbances  due  to 
pressure  of  the  cicatrix,  the  latter  may  be  removed 
and  the  space  in  the  bone  repaired. 

The  development  of  hydrocephalus,  which  may 
occur  after  operation  on  all  forms,  is  an  unfavorable 
sign. 

Fig.  143  shows  a  myelocele  of  the  lumbo-sacral 
region.  The  tumor  is  situated  symmetrically  in  the 
middle  line  and  has  a  wide  base.  At  the  base  the 
skin  is  thickened  (first  zone) ;  the  second  zone  (epi- 
thelio-serous)  shows  numerous  ramifying  vessels;  the 
third  zone  (vasculo-meduUary)  is  not  typical  and 
resembles  the  second  zone,  owing  to  epidermization 
of  the  latter  (cf.  Fig.  Ii2).  It  only  differs  from  the 
second  zone  in  its  bluish  color.  The  diagnosis  of 
myelocele  depended  on  the  absence  of  diminution  on 
pressure,  and  the  presence  of  paralysis  of  the  bladder 

393 


and  rectum,  and  pronounced  pes  varus  of  both  feet. 
Death  occurred  soon  after  birth. 

Fig.  144  shows  a  myelocystocele  situated  in  the 
lumbar  region,  and  covered  with  normal  skin.  A 
small  depression  in  the  surface  is  due  to  amniotic 
adhesions.  Under  the  skin  is  a  mass  of  fatty  tissue, 
while  a  deep  cystic  tumor  could  be  felt  more  deeply 
situated.  The  latter  could  be  almost  completely 
emptied  by  pressure.  There  were  no  motor  or  sen- 
sory disorders  present,  and  no  other  malformations. 
The  X-rays  showed  a  small  cleft  in  one  of  the  verte- 
bral arches  situated  a  little  to  one  side  of  the  middle 
line.  The  superficial  fatty  tumor  was  removed  and 
found  to  be  a  myxolipoma.  The  myelocystocele  was 
then  separated  down  to  the  bone,  ligatured  and 
removed.  The  gap  in  the  vertebra  was  closed  by 
transplantation  of  a  piece  of  bone  from  the  iliac  crest. 
Microscopic  examination  showed  the  pressure  of  cyl- 
indrical epithelium  in  the  inner  wall  of  the  cyst,  thus 
confirming  the  diagnosis. 


394 


Bockenheinier,  Atlas. 


Tab.  CXVI. 


Fig.  144.    .\\\elocystocele      Myxolipoma. 


Rebman  Company,  New- York. 


PES  VARUS 

Pes  varus  may  be  congenital  or  acquired.  The 
congenital  form  may  be  caused  by  arrested  develop- 
ment, or  may  be  secondary  to  pressure  caused  by 
amniotic  adhesions,  etc.  Congenital  pes  varus  is 
common  in  connection  with  myelocele,  and  is  due  to 
paralysis  of  the  nerves,  as  already  explained.  Ac- 
quired pes  varus  occurs  in  rickets,  and  as  the  result 
of  poliomyelitis  which  causes  paralysis  of  the  pro- 
nators and  dorsal  flexors  of  the  foot.  The  chief  effect 
takes  place  at  the  midtarsal  joint  and  consists  in 
supination,  plantar  flexion,  internal  rotation  and 
adduction.  Changes  also  occur  in  the  astragalus 
and  OS  calcis,  especially  in  long-standing  cases. 
These  changes  can  be  seen  by  the  X-rays.  There 
is  also  shortening  of  the  muscles,  tendons,  fascia 
and  ligaments,  especially  shortening  of  the  tendo 
Achillis  (talipes  equino-varus).  Decubital  ulcers 
may  form  on  the  outer  border  of  the  foot. 

Treatment.  In  congenital  clubfoot  treatment 
should  be  begun  as  early  as  possible,  by  repeated 
manual  correction  to  the  normal  position,  followed 
by  fixation  in  an  over-corrected  position  by  means  of 
plaster  of  Paris  bandages.  In  sucklings,  thin  strips 
of  cotton  bandages  soaked  in  mastic  solution  (tur- 
pentine 15,  mastic  12,  resin  28,  alcohol  (90  per  cent.) 
180,  ether  20)  may  be  used,  applied  to  the  foot  and 
leg  so  that  the  foot  is  fixed  in  the  over-corrected  posi- 
tion. This  treatment  should  be  kept  up  for  six 
months,  after  which  elastic  traction  may  be  ap{)lied 
to  the  foot  for  another  six  months.  In  older  children 
manipulation   must   be   performed   under   an   anaes- 

395 


thetic.  After  the  ninth  month  preliminary  tenotomy 
of  the  tendo  Achillis  is  necessary,  before  the  foot 
can  be  brought  into  the  proper  position.  To  prevent 
relapse  boots  should  be  worn  with  the  sole  raised  on 
the  outer  side,  but  care  must  be  taken  to  avoid  pro- 
ducing flat  foot.  In  pes  varus  due  to  poliomyelitis 
tendon  transplantation  may  be  performed.  Old- 
standing  cases  of  clubfoot  in  adults  require  oste- 
otomy, or  sometimes  more  extensive  operations  such 
as  disarticulation. 


396 


Bockenheimer,  Atlas. 


Tab.  CXVIl. 


O 


t/J 


X 

o 


O 
o 


O 
n 


M 


Rcbman  Comnanv.  W\»-Vorl(. 


Lymphangioma 

LYMPHANGIOMA  CONGENITUM  CYSTICUM  MULTIPLEX 

{Cotigenilal  Multiple  ajstic  lymphangioma) 
Plate  CXMI,  Fig.  145. 

The  term  lymphangioma  should  be  limited  to 
those  tumors  in  which  there  is  a  new  formation  of 
lymphatic  vessels.  A  number  of  growths  have  been 
included  in  the  term  lymphangioma  which  are  only 
formed  of  dilated  lymphatics,  without  any  new 
lymphatic  vessels.  Microscopic  examination  is  there- 
fore important  in  these  cases.  Clinically,  we  distin- 
guish simple,  cavernous  and  cystic  lymphangiomas; 
also  single  and  multiple.  In  the  great  majority 
of  cases  the  growths  are  congenital.  All  three  forms 
are  often  present  in  the  same  patient.  Lymphan- 
giomas may  occur  in  the  skin,  but  more  often  in  the 
subcutaneous  tissue;  also  between  the  muscles  and 
in  the  subserous  tissue.  The  term  simple  lymph- 
angioma is  WTongly  applied  to  lymphangiectases, 
which  form  lobulated  growths  covered  by  thickened 
skin  and  occur  on  the  head,  trunk  and  extremities. 
Simple  lymphangioma  occurs  most  commonly  in  the 
tongue  or  lips  as  a  circumscribed  growth.  The  skin 
or  mucous  membrane  is  always  somewhat  thickened 
and  adherent  to  the  growth.  The  isolated  circum- 
scribed form  of  simple  lymphangioma  may  be  mis- 
taken for  other  kinds  of  tumor,  but  transitional  stages 
to  cavernous  lymphangioma  are  often  found,  the 
diagnosis  of  which  is  easier. 

Cavernous  lymphangioma  is  always  a  diffuse  for- 

397 


mation,  of  soft  consistence  and  always  united  with 
the  skin  or  mucous  membrane  over  it.  The  tumor 
can  be  gradually  diminished  by  pressure,  as  the 
cavernous  spaces,  filled  with  lymph  and  lined  with 
epithelium,  communicate  with  the  neighboring  lym- 
phatic vessels.  Cavernous  lymphangioma  forms  a 
painless,  diffuse,  slow-growing  tumor  with  a  smooth 
surface  and  irregular  borders.  WTien  they  are  visible 
under  the  skin  or  mucous  membrane  they  have  a  pale- 
green  color,  in  distinction  to  the  reddish-blue  color 
of  cavernous  hemangioma.  They  occur  most  often 
in  the  cheeks,  tongue  and  lips,  giving  rise  to  enlarge- 
ment of  these  parts,  known  as  macromelia,  macro- 
glossia  and  macrocheilia.  They  are  generally  con- 
genital, or  appear  soon  after  birth.  Cavernous 
lymphangiomas  also  occur  in  the  neck,  causing  a 
dimpled  swelling  of  the  skin  by  their  numerous  pro- 
cesses, which  extend  in  all  directions  (Fig.  145).  As 
already  mentioned,  lymphangiomas  may  be  situated 
over  encephaloceles  or  myelocystoceles.  Gradual 
atrophy  of  the  bones  may  be  caused  by  the  pressure 
of  extensively  progressing  lymphangiomas. 

Cystic  lymphangioma  occurs  in  the  subcutaneous 
or  intermuscular  tissue,  most  often  in  the  side  of  the 
neck  (Fig.  145).  It  is  composed  of  large,  cystic 
cavities  lined  by  epithelium  and  containing  whitish 
or  brownish  fluid  (cystic  hygroma).  Cystic  lymph- 
angioma is  almost  always  congenital  and  is  character- 
ized by  its  slow  growth,  which  may  cease  after  some 
years.  The  skin  is  unchanged  and  can  be  raised 
from  the  tumor.  Fluctuation  is  present,  but  there  is 
no  diminution  of  the  tumor  on  pressure.  Extensive 
lymphangioma  of  the  neck  may  be  dangerous  from 
pressure  on  the  trachea.  Besides  the  neck,  the  growths 
may  also  occur  in  the  axilla,  the  popliteal  space,  the 
bend  of  the  elbow,  the  groin  and  the  sacral  region. 
Infants  with  congenital  lymphangioma  sometimes 
show  other  malformations,  and  are  often  incapable 
of  life. 

398 


Differential  Diagnosis.  Simple  lymphangioma 
which  occurs  in  the  form  of  a  small,  soft,  circum- 
scribed tumor,  may  be  mistaken  for  fibroma,  lipoma 
or  hemangioma.  Cavernous  lymphangioma  can  only 
be  mistaken  for  hemangioma,  as  no  other  tumor 
diminishes  on  pressure.  It  differs  from  hemangioma 
in  its  greenish  color  and  in  the  nature  of  its  contents. 
Cystic  lymphangioma,  when  it  occurs  in  the  form  of 
an  isolated  unilocular  cyst,  may  be  mistaken  for 
various  tumors ;  in  the  neck,  for  blood  cyst,  branch- 
ial cyst,  lipoma  or  dermoid. 

The  prognosis  of  lymphangioma  is,  on  the  whole, 
not  unfavorable,  on  account  of  its  limited  growth 
and  occasional  spontaneous  resolution. 

Treatment.  Circumscribed  lymphangioma  can 
be  excised.  In  diffuse  cavernous  lymphangiomas 
(macrocheilia,  macroglossia,  macromelia)  cunei- 
form excision  may  be  performed.  The  introduction 
of  magnesium  may  be  tried,  to  cause  thrombosis  and 
shrinking  of  the  tumor.  After  this  extirpation  is 
easier  and  infection  through  a  lymph  fistula,  which 
so  often  occurs  after  the  usual  operation,  is  avoided. 
Cystic  hygroma  is  best  treated  in  this  way.  Radical 
operations  should  not  be  performed  unless  the  child 
is  in  good  condition.  Puncture  and  injection  of 
tincture  of  iodine  are  unsafe  measures,  while  lymph 
fistula  often  remains  after  incision  and  plugging. 
Lymph  fistulas  must  always  be  removed  by  a  radical 
operation,  on  account  of  the  danger  of  infection 
through  them.  Lymph  fistulas,  which  occur  from 
injury  to  the  thoracic  duct  after  extensive  extirpation 
of  the  breast,  can  be  healed  by  plugging  with  acetate 
of  aluminium. 

Fig.  145  shows  a  congenital  tumor  involving  the 
lower  part  of  the  right  cheek,  the  whole  of  the  right 
side  of  the  neck  and  the  greater  part  of  the  left 
side   of  the   neck.     The   skin   was   unchanged   and 

399 


movable  over  the  tumor.  On  examination,  it  was 
found  to  be  a  multilocular  cystic  tumor.  There  was 
no  diminution  on  pressure.  The  tumor  also  extended 
to  the  floor  of  the  mouth,  so  that  the  tongue,  which 
also  contained  a  lymphangioma  (macroglossia), 
was  displaced  upwards.  The  greenish  surface  of 
the  cyst  was  visible  under  the  mucous  membrane 
of  the  mouth,  so  that  the  diagnosis  of  congenital 
multiple  cystic  lymphangioma  was  made.  On  ac- 
count of  the  situation  of  the  tumor  on  both  sides  of 
the  neck  in  the  submaxillary,  submental  and  parotid 
regions,  the  case  might  be  mistaken  for  an  affection 
first  described  by  Mikulicz,  in  which  there  is  sym- 
metrical enlargement  of  all  the  salivary  glands  and 
glands  of  similar  structure  in  the  head  and  neck.  In 
this  case,  however,  there  was  no  change  in  the 
lachrymal  glands,  which  are  usually  affected  in 
Mikulicz's  disease;  also  there  was  a  characteristic 
lymphangioma  in  the  tongue,  which  is  absent  in 
Mikulicz's  disease.  The  swelling  of  the  floor  of  the 
mouth  on  each  side  of  the  froenum  of  the  tongue 
resembles  a  ranula.  The  latter  is  a  cystic  formation 
arising  most  commonly  in  the  duct  of  the  sublingual 
gland,  more  rarely  from  the  incisive  gland  situated 
on  the  inner  surface  of  the  lower  jaw  in  the  middle 
line. 


400 


Teratomata 


TERATOMA  MONOGERMINALE  {Monogerminal  teratoma) 
Plate  CXVII,  Fig.  146. 


Teratomas  may  be  bigerminal  or  monogerminal.  In 
bigerminal  teratoma  there  is  a  true  double  formation 
— a  fetus  within  a  fetus.  In  monogerminal  teratoma 
there  is  perverted  development  in  one  embryo,  and 
all  the  tissues  are  derived  from  one  embryo  only. 
The  latter  includes  all  kinds  of  mixed  tumors  which 
are  formed  of  all  three  embryonic  layers  (epiblast, 
mesoblast  and  hypoblast).  Dermoid  cysts,  which  are 
formed  by  all  three  embryonic  layers,  belong  to  the 
teratomata.  A  distinction  between  monogerminal 
and  bigerminal  teratomata  is  not  always  possible, 
and  is  of  little  clinical  importance.  Teratomas  are 
rare  on  the  whole,  and  are  always  congenital.  They 
are  most  often  found  in  the  buccal  cavity,  where  they 
may  be  mistaken  for  naso-pharyngeal  polypi  (Fig. 
25).  They  also  occur  in  the  face,  neck  and  coccyg- 
eal region,  and  have  been  observed  in  the  mediasti- 
num and  abdominal  cavity.  They  may  attain  enor- 
mous dimensions,  and  have  then  an  irregular,  uneven 
surface.  The  consistence  also  varies,  some  parts 
being  cystic,  others  soft  and  others  hard.  Teratomas 
often  form  encapsuled  tumors.  They  may  cause 
extensive  destruction  by  pressure  on  the  neighboring 
parts.  A  distinction  between  teratomata  and  tera- 
toid mixed  tumors  is  clinically  impossible.  Diagnosis 
in  many  eases  is  only  made  after  examination  of  the 
extirpated  tumor. 

401 


Differential  Diagnosis.  Teratomas  which  ap- 
pear as  large,  congenital  tumors  can  generally  be 
recognized  by  the  above-mentioned  characteristics, 
especially  by  their  situation  in  the  embryonic  fissures. 
Diagnosis  is  assisted  by  the  X-rays  which  may  reveal 
bones  and  teeth,  which  ai-e  often  present  in  tera- 
tomas. Teratomas  occurring  in  the  thorax,  abdo- 
men and  pelvis,  especially  when  they  do  not  assume 
a  tumor  growth  till  later  years,  can  often  only  be 
diagnosed  by  operation. 

Treatment.  Teratomas  have  been  successfully 
removed  both  in  children  and  in  adults.  Extensive 
teratomas  (Fig.  146)  cannot  be  removed  by  operation. 
The  presence  of  other  deformities,  such  as  spina 
bifida,  and  the  feeble  condition  of  the  infants  often 
renders  operative  treatment  impossible. 

Fig.  146  shows  a  teratoma  of  the  left  side  of  the 
face,  almost  as  large  as  the  fist,  involving  the  left 
orbit  and  almost  the  whole  of  the  buccal  cavity,  and 
covered  by  livid,  movable  skin.  It  was  covered  by  a 
connective-tissue    capsule.  Further    examination 

showed  that  it  arose  from  the  base  of  the  skull,  but 
did  not  communicate  with  the  cranial  cavity.  The 
tumor  was  soft  and  fluctuating  in  some  places,  hard 
in  others.  Examination  by  the  X-rays  showed  the 
presence  of  a  piece  of  bone,  which  was  afterwards 
found  to  be  part  of  the  upper  jaw.  Further  exam- 
ination showed  that  the  tumor  consisted  of  neuroglia, 
neuroepithelium  and  cysts  lined  with  epithelium.  As 
it  consisted  of  epiblastic  products  only  it  must  be 
regarded  as  a  monogerminal  tumor  which,  in  this 
case,  originated  from  a  separated  portion  of  the 
epiblast.  This  view  is  supported  by  the  fact  that 
the  tumor  developed  in  a  region  (base  of  the  skull) 
where  separation  of  the  epiblast  is  possible.  On 
the  other  hand,  it  appears  far-fetched  to  consider 
the  tumor  as  a  bigerminal  teratoma  (fetus  within 

402 


fetus  by  inclusion)  simply  because  of  its  large  size 
at  birth. 

There  were  no  other  malformations  present  except 
mutilation  of  the  right  ear.  Death  occurred  soon 
after  birth. 


403 


DUCTUS  OMPHALO-MESENTERICUS  PERSISTENS 

(Persistent  OntpJialo-mesenteric  Duct) 
Plate  CX\1II,  Fig.  U7. 

The  omphalo-mesenteric  duct,  or  vitelline  duct,  is 
the  communication  between  the  alimentary  canal 
and  the  umbilical  vesicle  or  yolk-sac.  It  usually  dis- 
appears about  the  eighth  week  of  fetal  life.  In  some 
cases  this  duct  may  persist  and  is  then  known  as 
Meckel's  diverticulum,  which  arises  from  the  small 
intestine  about  ten  inches  above  the  ileocsecal  valve. 
This  diverticulum  may  lie  free  in  the  abdominal 
cavity,  where  it  may  cause  intestinal  obstruction  by 
becoming  entangled  with  the  intestines;  or  it  may 
become  attached  to  the  umbilicus,  or  extend  a  short 
distance  into  the  umbilical  cord.  In  the  latter  case 
it  may  become  opened  after  birth  when  the  umbilical 
cord  has  separated,  thus  giving  rise  to  an  umbilical 
fistula,  discharging  faeces  from  the  umbilicus  when 
the  whole  length  of  the  duct  is  open  as  far  as  the 
intestine.  When  the  intestinal  end  of  the  duct  is 
closed,  the  remainder  may  persist  as  a  small  fistula 
discharging  mucoid  secretion;  or  it  may  become 
dilated  into  cystic  formations. 

In  umbilical  fistula  there  is  a  red  globular  swelling 
with  a  small  depression  at  its  apex,  situated  at  the 
navel.  The  surface  of  the  swelling  is  formed  by 
mucous  membrane.  A  probe  can  be  passed  through 
the  depression  as  far  as  the  small  intestine,  and  the 
greater  part  of  the  faeces  are  discharged  through  the 
fistula,  causing  inflammation  of  the  skin  surrounding 
the  navel.  Death  often  occurs  from  prolapse  of  the 
small  intestine. 

404 


Bockenheimer,  Atlas. 


Tab.  CWIII. 


5 

o 


zr. 


u 


Rebman  Company,  Neir-York. 


Differential  Diagnosis.  Infection  of  the  navel 
with  the  formation  of  granuhition  tissue  may  resem- 
ble the  above  condition.  Other  fistulas  may  also 
occur  in  the  umbilicus.  The  urachus,  which  repre- 
sents the  remains  of  the  communication  between  the 
bladder  and  the  allantois  in  fetal  life,  may  remain 
open  and  form  a  fistula  at  the  umbilicus.  Normally 
the  urachus  becomes  obliterated  and  forms  the  median 
ligament  of  the  bladder.  Fistula  of  the  urachus  is 
diagnosed  by  discharging  urine.  Like  fistula  of  the 
vitelline  duct,  fistula  of  the  urachus  usually  appears 
after  separation  of  the  umbilical  cord.  The  nature 
of  the  fistula  is  not  always  determined  by  probing; 
a  more  certain  method  of  diagnosing  fistula  of  the 
vitelline  duct  is  by  feeding  with  powdered  charcoal, 
which  then  appears  at  the  navel.  The  diagnosis  can 
sometimes  be  made  by  chemical  and  microscopical 
examination  of  the  secretion.  Tuberculosis  of  the 
intestine,  actinomycosis,  peritonitis,  empyema  of 
the  gall  bladder,  injuries  of  the  bladder,  and  der- 
moids may  all  give  rise  to  fistula  at  the  navel. 

Treatment.  Fistula  of  the  vitelline  duct  can  some- 
times be  prevented  by  discovering  the  condition  before 
tying  the  umbilical  cord.  The  cord  is  then  thicker  than 
usual  at  its  base.  The  end  of  the  duct  can  then  be  re- 
duced and  the  cord  tied  further  away  from  the  navel. 

In  cases  of  complete  fistula  leading  to  the  intestine 
laparotomy  is  necessary,  with  resection  of  the  diver- 
ticulum and  suture  of  the  intestine.  Fistula  of  the 
urachus  must  be  separated  down  to  the  bladder  and 
removed,  and  the  bladder  sutured. 

Fig.  147  shows  a  case  of  complete  fistula  of  the 
vitelline  duct.  The  infant  was  in  a  bad  condition 
from  prolapse  of  the  gut,  evacuation  of  faeces  from 
the  navel,  and  inflammation  of  the  surrounding  skin. 
Laparotomy  was  performed  but  the  operation  was 
unsuccessful. 

405 


HERNIA  FUinCULI  UMBILICALIS  CONGENITA 

(Congenital  Umbilical  Hernia) 
Plate  CXVIII,  Fig.  Us. 

Congenital  umbilical  hernia  must  be  regarded  as  a 
malformation,  and  forms  a  large  tumor,  containing 
intestine  and  often  also  the  liver.  It  is  often  asso- 
ciated with  various  forms  of  spina  bifida,  or  with 
ectopia  of  the  bladder.  Cases  of  extensive  umbilical 
hernia  are  due  to  arrested  development  causing  in- 
complete closure  of  the  abdominal  walls.  Umbilical 
hernia  may  also  be  acquired.  In  this  case  the  ab- 
dominal walls  are  closed,  the  umbilical  ring  is  small, 
the  hernia  is  smaller  and  more  cylindrical,  and  the 
contents  consist  of  small  intestine.  Acquired  hernia 
may  be  so  small  as  to  be  overlooked  at  birth,  and  may 
then  be  included  in  the  ligature  of  the  umbilical  cord. 
The  base  of  the  cord  should,  therefore,  always  be 
examined  to  see  if  it  contains  intestine. 

Congenital  umbilical  hernia  forms  a  large  globular 
swelling  in  the  region  of  the  navel  (Fig.  148).  The 
surface  is  destitute  of  cutaneous  covering  and  shows 
the  greenish-yellow  remains  of  the  amnion.  The 
remains  of  the  umbilical  cord  is  generally  seen  at  one 
side  of  the  swelling.  In  rare  cases  epidermization 
takes  place  at  the  borders;  more  commonly  the 
swelling  ruptures  from  pressure,  with  consequent 
prolapse  of  the  viscera  and  death  from  peritonitis. 

Differential  Diagnosis.  Both  the  congenital 
and  the  acquired  forms  of  umbilical  hernia  are  so 
characteristic  that  they  cannot  be  mistaken  for  any 
other  condition. 

406 


Treatment.  The  occurrence  of  symptoms  of 
intestinal  obstruction,  or  tlireatening  perforation  of 
the  sac  indicate  immediate  laparotomy,  with  excision 
of  the  sac,  reduction  of  its  contents  and  closure  of  the 
abdominal  walls.  In  some  cases  the  viscera  are 
adherent  to  the  sac  and  require  separation.  Reduc- 
tion of  the  visceral  contents  is  sometimes  difficult  or 
even  impossible,  especially  when  the  liver  is  con- 
tained in  the  sac.  If  operation  is  not  urgent  it  may 
be  postponed  till  the  child  is  stronger,  the  sac  being 
supported  by  bandaging  in  the  meantime. 

Acquired  umbilical  hernia  may  occur  during  the 
first  month  after  birth,  as  the  umbilical  ring  takes 
several  weeks  to  close  completely.  Anything  which 
causes  the  infant  to  cry  may  be  an  exciting  cause  for 
hernia,  also  straining  from  phimosis,  etc.  Many 
cases  become  cured  without  treatment.  Non-opera- 
tive treatment  consists  in  placing  a  metal  disk 
wrapped  in  plaster  over  the  umbilical  ring,  after 
reduction  of  the  hernia,  and  bringing  the  skin  of  the 
abdomen  together  over  it  by  means  of  plaster.  The 
disk  must  be  larger  than  the  hernial  opening.  Small 
openings  may  be  closed  in  this  way  after  nine  months' 
treatment.  Larger  openings  with  separation  of  the 
recti  muscles  above  the  umbilical  ring  require  lapa- 
rotomy. In  older  children,  especially  girls,  this 
should  always  be  performed.  The  operation  con- 
sists in  extirpation  of  the  whole  umbilical  ring  and 
suture  of  the  abdominal  walls  with  wire. 

In  Fig.  148  the  hernial  sac  contained  the  intestine 
and  liver,  which  were  reduced  with  great  difficulty, 
so  that  the  abdominal  walls  when  sutured  were  under 
great  tension.  The  infant  died  soon  after  the  opera- 
tion. 


407 


AMPUTATIONES  AMWIOTICiE    (Amniotic  Amputations) 
Plate  CXIX,  Fig.  149. 

Malformations  of  the  extremities  include  amelus 
and  phocomelus.  In  amelus  the  extremities  are 
absent  or  only  represented  by  stumps.  This  condi- 
tion may  affect  all  four  extremities,  both  arms  or 
legs,  or  one  arm  or  leg.  In  phocomelus  there  is 
arrested  development  of  the  proximal  segments  of 
the  arms  or  legs,  or  of  all  four  extremities.  The 
hands  or  feet  are  then  situated  directly  on  the  trunk. 
Some  of  these  cases  attain  adult  age,  and  one  has 
been  known  to  live  to  sixty-two.  [Several  such  cases 
were  among  Bartium's  freaks.] 

The  so-called  spontaneous  amputations  of  various 
parts  of  the  extremities  are  caused  by  pressure  of 
amniotic  bands  or  the  umbilical  cord.  The  ends  of 
the  amputations  are  then  pointed.  In  other  cases 
there  is  not  complete  amputation  but  constriction, 
resulting  in  deep,  circular  grooves  extending  to  the 
bone  (Fig.  149).  In  spite  of  the  depth  of  the  grooves, 
the  circulation  remains  normal,  but  there  is  often 
elephantiasic  thickening  from  lymphatic  congestion. 
In  some  cases  the  bones  are  constricted,  as  shown  by 
the  X-rays.  The  remains  of  the  amniotic  bands  are 
often  present  in  the  constricted  places. 

Other  malformations,  also  due  to  tightness  of  the 
embryonic  membranes,  are  synechia  of  the  fingers 
(webbed  fingers),  hare-lip,  cleft-palate,  transverse 
fissure  of  the  cheek,  and  fissure  of  the  tongue. 

Treatment.  When  the  constricted  parts  are 
functionless  they  should  be  amputated.  Elephanti- 
asis may  be  treated  by  cuneiform  excision. 

408 


Bockenheimer,  Atlas. 


lab.  CXIX. 


hig.  14y.    Ainputalioiies  aiiiiiioticae. 


Pfhmnn   Pnninanv.    Npw-York. 


In  Fig.  149  the  function  of  the  fingers  was  normal 
so  that  no  operation  was  necessary.  In  this  case 
there  was  also  hare-lip  and  cleft-palate,  which  were 
operated  upon. 


409 


AKROMEGALIA   (Acromegaly) 
MAKROMELIA   {Macwmelia) 
MAKROGLOSSIA  (Macroglossia) 
Plate  CXX,  Fig.  150. 

The  term  Acromegaly  is  applied  to  a  condition  in 
which  there  is  enlargement  of  the  terminal  portions 
of  the  body — the  hands,  feet,  nose,  cheeks,  tongue 
and  ears.  The  enlargement  affects  all  the  tissues 
(true  giantism)  and  does  not  appear  till  after  the 
termination  of  the  period  of  growth,  thus  differing 
from  congenital  giantism.  In  some  cases  there  is 
increased  growth  of  hair,  and  curvature  of  the  verte- 
bral column.  The  disease  causes  considerable  dis- 
figurement of  the  face.  It  generally  appears  between 
the  twentieth  and  fortieth  years  and  may  remain 
stationary.  In  many  cases  there  is,  first  of  all, 
hypertrophy  of  the  bones  of  the  hands,  feet  and  face. 

The  disease  has  been  attributed  to  changes  in  the 
pituitary  body  (hypertrophy,  adenoma,  sarcoma, 
cyst) ;  to  changes  in  the  thyroid  gland,  pancreas, 
genital  glands;  to  persistence  of  the  thymus;  to 
nervous  influence,  since  nervous  disorders  have  been 
observed  in  the  hypertrophied  extremities;  also  to 
a  congenital  condition.  The  most  probable  of  these 
is  enlargement  of  the  pituitary  body,  which  can  be 
demonstrated  by  widening  of  the  sella  turcica,  shown 
by  the  X-rays.  Large  tumors  of  the  pituitary  body 
may  press  on  the  optic  nerve  and  nerves  of  the 
ocular  muscles. 

The  prognosis  is  not  unfavorable,  as  severe  dis- 
turbances only  occur  after  the  disease  has  existed 
for  many  years. 

Differential  Diagnosis.  Partial  giantism,  which 
also  begins  in  the  hands  and  feet,  differs  from  acro- 

410 


Bockeiiheimer,  Atlas. 


Tab.  CXX. 


Fiu.  IJO.    Akiomeyalia  —  Alakroniclia       A\akroglossia. 


Rebiiian  Comnanv.  NeT-N'ork 


megaly  by  being  congenital.  In  ieontiasis  ossea  there 
is  enlargement  of  the  bones,  while  the  soft  parts  are 
more  often  atrophied.  Acromegaly  affecting  one  ex- 
tremity only  might  be  mistaken  for  osteitis  deformans, 
or  for  chronic  osteomyelitis,  as  there  may  be  length- 
ening of  the  bone  in  both  these  diseases.  Acro- 
megaly differs  from  elephantiasis  in  the  presence  of 
enlargement  of  the  bones,  which  can  be  shown  by 
the  X-rays.  Acromegaly  commencing  in  the  face 
might  possibly  be  mistaken  for  tumor  of  the  upper 
maxilla,  but  there  is  usually  early  hypertrophy  of  the 
cheeks  (macromelia),  lips  and  tongue  (macroglossia), 
and  of  the  hands  and  feet. 

Treatment.  Thyroid  extract  and  extract  of 
pituitary  gland  have  been  recommended.  Tumor 
of  the  pituitary  gland  may  be  removed  by  operation. 
Extensive  enlargement  of  the  soft  parts  may  be 
diminished  by  cuneiform  excision. 

Fig.  150  shows  marked  hypertrophy  of  the  right 
side  of  the  face.  The  right  ear  is  considerably 
larger  than  the  left,  and  there  is  hypertrophy  of  all 
the  tissues  of  the  cheek.  The  right  side  of  the 
tongue  is  enlarged,  somewhat  resembling  cavernous 
lymphangioma,  but  differing  in  being  unilateral. 
X-ray  examination  showed  unilateral  enlargement  of 
the  upper  and  lower  maxillary  bones.  The  fingers 
and  toes  on  the  right  side  had  increased  in  size  for 
some  years.  The  X-rays  showed  widening  of  the 
sella  turcica  indicating  the  presence  of  a  tumor  of 
the  pituitary  body.  As  the  patient  suffered  no 
trouble  from  the  disease,  he  refused  operation. 


411 


Complete  Index 


Abscess.  19 
bone,  189 
burrowing,  191 
cold,  1S9,  335 
embolic,  190 
epidural,  257 

gummatous,  299,  314 
hot,  189 

lymphadenitis,  189 
milk,  193 

metastatic,  190 

paramammillarj-.  189 

subcutaneous,  189 

subperiosteal,  256 

thrombo-phlebitis,  186 
Achylodynia,  378 
Acne  rosacea,  140 
Acrania,  384 
Acromegaly,  381,  410 
Actinomycosis,  40,  293 
Adenoids,  44 
Adenoma,  72 

malignant,  72 

sebaceous,  72 
Adenophlegmon,  237 
Amelus,  408 

Amniotic  amputation,  381,  408 
Anchylosis,  fibrous,  335 

osseous,  338 

tuberculous,  329 
Anencephalus,  .381 
Aneurism,  57,  87 

arterio-venous,  169 

cirsoid,  137 

consecutive,  170 

false,  169 

pulsating,  172 

racemose,  171 

traiunatic,  170 

true,  169 

varicose,  170 
Angina  Ludovici,  237 
Angina,  syphilitic,  301 
Angiolipoma,  104 
Angioma,  cavernous,  8,  152 

fissural,  152 

hypertrophic,  152 

neuropathic,  1.53 

plexiform,  152 

rae<>mose,  1.52 
Angiosarcoma,  34,  74 

cutaneous.  46,  74 

plexiform,  74 
Animal  baths,  284 


Anthrax,  202,  287 
Anti-streptococcus  serum,  271 
Antitetanin,  162 
Anus,  hemorrhoids  of,  102 
Arteritis,  sj-philitic,  304 
Arteriosclerosis,  370,  374 
Arthritis,  82,  337 

fibrinous,  283,  329,  338 

fungoid.  328,  335 

gonorrhceal,  282 

gouty,  377 

phlegmonous,  282 

purulent,  283.  329,  .337 

rheumatic,  283 

tuberculous,  284,  335,  337 

urica,  377 
Asphyxia,  local.  368 
Atheroma,  24,  374 

carcinoma,  24 

Bacteriaemia,  261 
Balanitis,  92 

Ballottenient  of  patella,  339 
Balsam  of  Peru,  146 
Barlow's  disease,  157 
Basal-celled  cancer,  4,  74 
Basedov's  disease,  87 
Birth  marks,  134 
Boil.  196 

Bone  plugging,  253 
Botrioraycosis,  46 
Breast  cancer,  16 
Bronchocele,  85 
Bubo,  mdolent,  300 

inguinal.  278 
Bullet  wounds.  162 
Burn,  X-ray,  305 
Burns,  30,  355 

internal,  359 
Biu-sitis,  82 

prepatellar,  82,  84 

Cadaveric  tubercle,  322 
Cancer  en  cuirasse,  23 
Cancroid,  3 

Capsule,  sequestral,  248 
Caput  medusa,  174 
Carbolic  gangrene,  345,  354 
Carcinoma,  branchial,  40 
Carbuncle,  202 

diabetic.  202 

facial,  202 

buccal,  10 

disseminated,  22 


413 


Carbuncle,  glandular,  16 

inoperable,  4,  20 

metastatic,  40,  58 

naevus.  24 

papillary,  30 

paramammary,  18 

of  basal  cell,  5 

of  breast,  16 

of  cicatrLx,  30 

of  connective  tissue,  20 

of  face.  1 

of  forehead,  1 

of  hand.  31 

of  lip,  6 

of  mamma.  16,  22 

of  nipple,  16 

of  nose,  1 

of  penis.  27 

of  skin,  4,  6.  24,  30 

of  tongue,  6,  13 
Caries  sicca,  329 
Cattle  fever,  2S7 
Cavernoma,  66 

of  tongue,  66 
Cephalhematoma,  161 
Cephalocele,  383 
Cephalocele,  see  Encephalocele 
Chancre,  phagedenic,  300 

syphilitic,  299 

tongue,  311 
ChilbLains,  362 
Chimney-sweep's  cancer,  30 
Chiragra.  377 
Chonilrofibroma,  69 
Chondro-lipoma,  99,  104 

myxoma,  99 

sarcoma,  99 
Chondroma,  35,  99 
Chondromyxonia ,  99 
Chondromyxosarcoma,  62 
Chondrosarcoma,  57,  62 
Claudication,  intermittent,  375 
Cla\'us,  232 
Claw-hand,  120 
Combust  io,  355 

Compression  of  ulnar  nerve,  120 
Condylomata,  302 
Condylomata  lata,  301 
Congelatio,  .360 
Contracture,  of  arm,  122 

arthrogenous,  126 

cicatricial,  116 

dermatogenous,  118 

Dupwjtren' s .  115 

ischaemic,  122 

hysterical,  120 

myogenous,  123 

neurogenous,  120 

palmar.  115 

paralj'tic,  120 

tendogenous,  118 
Corn,  232 

Corona  veneris.  301 
Corpus  cavernosum,  28 
Coxa  vara.  129 
Craniotabes,  128 
Cr^de,  unguentum,  188 
Cretinism,  88 


Cutaneous  cancer,  72 

fibroma,  136 

horn,  72 
Cystadenoma,  69 
Cysts,  bone,  19 

branchial,  92 

dermoid.  92 
Cystic  goitre,  85 

hygroma,  84 
Cysto-sarcoma  (of  breast),  49 

Dactylitis,  syphilitic,  305,  317,  343 
Decollement  de  la  peau,  148 
Decubital  ulcer,  350 
Delirium,  209 
Dermoid  cysts,  92 
reciurent.  92 
Detachment  of  skin,  148 
Diabetes,  370 

Diathesis,  hemorrhagic,  156 
Diffuse  hematoma.  156 
Dislocation  of  shoulder,  259 
Dislocation  with  fractm-e  of  leg,  132 
Dissemination,  cancerous,  22 
Duct,  persistent  omphalo -mesenteric, 

387,  404 
Dupuytren's  contracture,  115 

Ecchondroma,  99 
Ecchondroses,  99 
EcchjTiioses,  160 
Eczema  of  nipple,  16.  22 
Elephantiasis,  142,  145 

acquired,  142 

hard,  142 

IjTnphangiectatic,  142 

nervorum,  137,  139 

penis,  142 

soft,  142 
Embolism,  tuberculous,  319 
Empyema,  179 

of  antrum,  241 
Encephalocele,  94,  381,  383 
Encephalomalaeia,  41 
Enchondroma.  99 
Endarteritis.  304.  347 
Endocarditis,  ulcerative,  266 
Endothelioma,  32.  74 

of  parotid,  77 
Endothelial  cancer,  77 

sarcoma,  77 
English  disease,  128 
Ephelides.  134 
Epidermoids,  92 
Epithelial  cysts,  92 
Epithelioma,  21 
Epulis,  34,  64 
Erysipelas.  204 

bulbous,  205 

chronic,  211 

curative,  206 

erythematous,  204 

gangrenous,  204 

hemorrhagic,  208 

migrating,  204 

phlegmonous,  204 

recurrent.  204 
Erysipeloid,  211 
414 


Exostoses,  cartilaginous,  62 
malignant,  62 
subungual,  126 

False  joints.  132 
Fibro-adenoma,  19,  49,  69 

cystic,  69 
FibroUpoma,  97,  104 

pendulous.  104 
Fibroma,  96.  116 

cutaneous,  136 

intracanalicular,  69 

melanodes.  134 

vaginae  tendinis,  96 
Fibromata  ani,  102 

mollusca,  136,  139 
Fibromatosis.  137,  142 
Fibrolipoma,  104 
Fibromyoma,  96 
Fibromyxoma,  96 
Fibrosarcoma,  36,  60,  64 
Fistula,  IjTnph,  399 

from  foreign  body,  109 

of  neck.  110 

mammarj'.  195 

osteomvelitic,  259 

rectal.  333 

umbilical,  404 

vesical.  294 
Flatfoot,  174.  177 
Folliculitis.  196 
Fracture,  treatment  of,  128 

pathological,  57 

rickety,  128 
Fracture-dislocation,  132 
Framboesia,  46 
Freckles,  134 
I'rost^bite,  360 
Furuncle,  196 
Furunculosis,  82,  196 

Ganglion  of  wrist,  80 

Gangrene,  angioneurotic,  347 
angiosclerotic,  348 
carbolic.  345,  354 
diabetic,  3.50.  370 
dry,  345,  370 
embolic,  347 
infective,  350 
moist,  317,  344,  350 
progressive,  345 
Raynaud's,  347,  367 
senile,  .346 
spontaneous,  350 

Gaseous  phlegmon,  274 

General  infection,  261 

Genu  valgum,  129 

Geographical  tongue,  298 

Giantism,  64,  143,  410 

Glanders,  287 

Cilands,  tuberculous,  324 

Gliosarcoma,  35 

Glossitis,  298 

Glossy  skin.  220 

Glottis,  oedema  of,  239 

Goitre,  85 

exophthalmic,  87 

Gonococcal  metastases,  282 


41.5 


GonorrhoDal  arthritis,  282 
Gout,  377 
Grafting,  108 
Granulations,  108 
Grave's  disease,  87 
Greenstick,  128 
Gumma,  299,  302 

of  lip  and  no.se,  299,  313 

of  tongue,  299,  312 
Gummatous  abscess,  314 

astoitis,  315 

ulcer,  316 

Hallux  valgus,  126 
Hammer-toe,  126 
Hebra's  ointment,  146 
Heat  stroke.  359 
Hemangio-endothelioma,  152 
Hemangioma,  cavernous,  66,  150,  166 

simple.  152 

subcutaneous,  166,  168 
Hemarthrosis.  120,  158 
Hematoma,  diffuse,  156 

ear,  150 

pulsating,  160 

subcutaneous,  156,  160 
Hemophilia,  1.56 

Hemorrhage  from  compression,  164 
Hemorrhoids,  102 
Hernia,  abdominal,  406 

mnbilical.  .381,406 
Hodgkin's  disease,  40 
Hordeolum,  196 
Horn,  cutaneous,  72 
Hospital  gangrene,  345 
Housemaid's  knee,  82 
lluichinson's  teeth,  306 
Hydrocephalus,  393 
Hydrops,  tuberculous,  328,  330,  389 
Hygroma,  82 

cystic,  399 

multilocular,  84 

tuberculous,  342 
Hyperkeratosis,  10 

Icterus,  hematogenous,  267 
Implantation  carcinoma,  6 
Infection,  generalized,  261 

pyogenic,  179 
Infective  diseases,  350 
Inflammation.  90 
Interdigital  whitlow.  227 
Intestine,  actinomycosis  of,  293 

anthrax  of,  287 

tuberculosis  of,  341 
Iodoform  bone  plugs,  253 
Ischaemic  contracture  of  arm,  122 

Joint  effusion,  248 

Keloid,  after  laparotomy,  113 

after  vaccination,  113 
Keratitis,  parenchymatous,  306 
Keratoma,  senile.  72 
Knee,  hygroma  of,  84 
Kyphosis,  129 

Lassar's  zinc  paste,  146 
Laparotomy  keloids,  113 


Leg.  fracture  of,  128,  132 

varicose  ulcer,  145 
Lentigines,  134 
Leontiasis  ossea,  410 
Leucoplakia,  11 

preputial,  27 
Lightning  stroke,  355 
Lingua  bifida,  312 
Lingua  geographica,  298 
Lipoma,  diffuse,  104 

symmetrical,  94,  104 
Lipomatosis,  106 
Lung,  actinomycosis  of,  293 

anthrax  of,  289 

ca\itation  of.  268 

tuberculosis  of,  323 
Lupus,  8 

exfoliating,  10 

exulcerans,  10 

hypertrophic,  10 

of  face,  9 

ulcerative,  10 
Lupus-carcinoma.  9 
Luxatio,  132 
Lymphadenitis,  acute,  278,  323 

axillary,  286 

cerv'ical,  279,  325 

chronic,  280 

circumscribed,  281,  292 

difi'use,  278 

inguinal,  278 

ne~ck,  325 

tuberculous.  280,  325 
Lymphangio-endothehoma,  74 
Lymphangio-fibroma,  134 
Lymphangioma,  cavernous,  67,  397 

circumscribed,  399 

cystic,  67,  397 

multiple,  381,  397 

simple,  67,  397 
Lymphangitis,  196,  200,  213,  223 

carcinomatous,  16 

chronic,  23 

tuberculous.  323 
Lymphatic  glandular  abscess,  281 

phlegmon,  278 

tuberculosis,  334 
Lymph  fistulas,  399 
Lymphoma,  carcinomatous,  16 

leukaemic,  40 

malignant,  39 

sarcomatous,  34,  39,  48 

syphilitic,  39 

tuberculous,  317,  334 
Lymphosarcoma,  34,  39,  40,  48 
Lymphvarix,  142 

Macrocheilia,  410 
Macroglossia,  381,  410 
Macromelia,  381,  410 
Malformations,  381 
Malignant  oedema,  274 

pustule,  287 
Marginate  glossitis,  298 
Malum  perforans,  367 
Mastitis,  192 

carcinomatous,  23 

clironic  cystic,  70 


41G 


Mastitis,  interstitial,  70,  193 

neonatorum,  192 

phlegmonous,  192 

puerperal.  192 

superficial,  193 

tuberculous,  193 
Meckel's  diverticulum,  404 
Median  fistula  of  neck,  110 
Mediastinitis,  87 
Melanocarcinoma,  32,  39,  48 
Melanoma,  32 
Melanosarcoma,  32,  48 
Meningitis,  392 
Meningocele,  390 
Meningococcus  serum,  285 
Mesenteric  tuberculosis,  381,  404 
Metastases,  58 
Mikulicz's  disease,  94,  399 
Miliary  tuberculosis,  333 
Milk  fistula,  195 
Miner's  elbow,  82 
Mixed  infection,  181 
Mixed  tumor,  19,  77 
Mucous  membrane,  erysipelas  of,  204 

carcinoma  of,  13 

papilloma  of,  11 

tuberculosis  of,  332 
Mucous  patch,  301 
Multilocular  hygroma  of  knee,  84 
Mummification,  345 
Myelocele,  381,  388 
Myelocystocele,  381,  388 
Myeloma,  57 
Myxcedema,  88 
Myxolipoma,  104,  381,  388 
Myxosarcoma,  60 

Nffivi,  1.34 

NsBvus  carcinoma,  24 

hairy.  134 

lymphangiectatic,  134 

neuromatous,  136 

pigmentary,  134 

vascular,  134,  155 

verrucosus,  135 

vinous,  155 

warty,  24 
Nasopharyngeal  polypi,  42,  45 
Necrosis  of  bone,  287,  371 

fascia,  350 
Neck,  fistulas  of,  110 

]ihlegmon  of,  237 
Nephritis,  265 
Nerve,  elephantiasis,  139 

compression  of,  120 
Neurasthenia,  traumatic,  214 
Neurofibroma,  136 
Neurogenous  contractiu'e,  120 
Neuroma,  137,  139 

CEdema,  acute,  274 

malignant,  209,  274 
Omphalo-mesenteric  duct,  381 
Onychogryposis,  376 
Osteitis,  deformans,  251 

fibrous,  56 

gummatous,  299,  315 

purulent,  2.50 


Osteitis,  tuberculous,  317,  343 
Osteochondritis,  syphilitic,  305 
Osteocopic  paiiis,  304 
Osteomalacia,  129 
Osteomyelitis,  58,  244,  250,  259,  327 

acute,  244,  252,  257 

chronic.  253.  259 

of  humerus,  259 

of  jaw.  255 

of  lower  maxilla,  255 

of  scapula,  257 

of  tibia,  244.  260 
Osteosarcoma,  55 
Othematoma,  150 
Otitis  media,  245 
Ozoena,  303 

Pachydermia.  142 

acquired,  145 

lymphangiectatic,  145 
Paget's  disease  of  nipple,  16,  22 
Panaritium  (sec  whitlow).  213 
Papilloma,  inflammatory  of  skin,  90 

of  tongue,  6.  Ill 

malignant.  91 
Paramammillarj'  abscess,  189 
Parotid,  endothelioma  of,  77 
Paronychia.  228 
Parulis,  241 
Payr's  magnesium,  68 
Pediculosis,  292 
PeK-is,  rickety,  128 
Pemphigus,  305 
Pendulous  fibrolipoma.  97,  104 
Penis,  elephantiasis,  142 

carcinoma,  27 
Perforating  ulcer  of  foot,  367 
Periadenitis,  278 
Periarteritis,  304 
Pericarditis,  350 
Periostitis,  albuminous,  249 

alveolar,  241 

gummatous.  241 

ossifying,  248 

purulent,  241 
Periphlebitis.  186 
Peritoneal  tuberculosis,  333 
Pernio,  360 
Pes  planus,  177 

valgus,  129.  174,  177 

varus,  381,  388,  395 
Petechia,  160,  164 
Phagocytosis,  179 
Phimosis,  92 
Phlebectasis.  174 
Phlebitis,  thrombo,  186 
Phleboliths,  130 
Phlegmasia  alba  dolens.  187 
Phlegmon,  234,  274 

emphysematous,  274 

gaseous,  274 

gangrenous.  274 

neck,  237 

putrefactive,  234 

submaxillary,  237 

wooden,  2.38 
Phocomelus,  408 
Phosphorous  necrosis,  256 


417 


Pigmentary  na;vi,  134 

carcinoma,  25 
Plague.  .Siberian,  289 
Pleuritis.  3.50 

tuberculous,  333 
Podagra.  377 

Polypus,  malignant  nasal,  42.  45 
Polyvalent  serum.  271 
Putt's  disease,  327 
Prepatellar  bursiti.s,  82,  84 
Pseudarthrosi.s,  132 
Pseudoleukaemia,  40 
Psoriasis.  301 

bucail,  9 

lingual.  9 
Puerperal  mastitis.  192 
Purpura  hemorrhagica,  157 
Pustule,  malignant,  202,  287 
Pyaemia,  261 

chronic.  294 
Pyogenic  infections,  179,  200,  262 

Quinsy,  245 

Rag-sorters'  disease,  287 
Raynaud's  disease,  367 
Recklinghausen's  disease,  389 
Rhachischisis,  381,  383,  387,  388 
Rhachitis.  128 
Rheumatism,  282 
Rhinitis,  atrophic,  43 
RhinophjTna,  140 
Rhinoscleroma,  140 
Rickets,  128 
Rider's  bone,  169 
Riedel's  preparation,  372 
Rinderpest,  287 
Roentgen- ray  burn.  365 
Rosary,  rickety,  128 
Roseola,  301 

Round-celled  sarcoma.  35,  46 
Rupia,  syphilitic,  301 

Saber  blade  tibia,  305 
Sand  baths,  284 
Sarcocele,  34 
Sarcoma,  cavernous,  46 

central,  53 

cutaneous.  34,  52 

endothelial.  74 

epipharyngeal.  34,  42 

fascial.  34,  60  _ 

fungoid,  34.  46 

giant-celled.  35,  64 

hemorrhagic.  52 

inoperable,  58 

mamman,-.  34,  49 

myeloid,  1.58 

multiple,  52 

osteo,  .58 

parosteal,  57 

peripheral  (of  humerus),  34,  55 

phyllodes,  ()9 

pigmentary,  53 

round-celled,  35,  46 
Sarcomata,  34 
Scars,  hypertrophic,  114 
Scleroderma,  122 


Sclerosis,  299,  311 
Scoliosis.  129 
Scrofula.  321 
Scrofuloderma,  319 
Scurvy — rickets,  157 
Sebaceous  adenoma,  72 

furuncle,  196 
Seborrhoea,  senile,  1 
Sepsis,  261 
Septicaemia,  261 
Septico-pysemia.  261 
Sequestrotomy,  247 
Serous  effusion,  246 
Serum,  polyvalent,  271 
Silver,  colloidal.  271 
Skin,  carcinoma  of.  30 

detachment  of,  148 

endothelioma.  74 

gangrene  of.  345 

grafting  of.  108 

horns  of,  72 

papilloma  of,  90 

sarcoma  of,  53 

tuberculosis  of,  322 
Snowball  crunching,  120,  157,  160 
Spina  bifida,  388 

occulta,  389 

ventosa,  343 
Spindle-celled  sarcoma,  35,  46 
Spirochaeta  pallida,  299 
Splenic  fever,  287 
Spondylitis,  tuberculous.  327 
Spontaneous  gangrene.  350 
Staphylococcal  infection,  182 

mycosis,  262 

phlegmon,  204 

serum.  221 
Staphylolysin,  249 
Stomatitis,  309 
Streptococcal  infection,  263 

mycoses,  263 

osteomyelitis,  250 

phlegmon,  276 
Strictures,  303 
Struma  cystica,  85 
Subcutaneous  hemangioma,  166,  168 

hematoma,  160 
Subluxation,  338 
Suffusions,  160 
Suggillations,  160 
Sunstroke,  359 
Sweat-gland  abscess.  189 
furuncle,  196 
Syphilide,  macular,  301 

papular,  301 
Syphilis,  acquired.  299 

congenital,  305 

malignant,  305 

Teeth,  syphilitic,  306 
Telangiectases,  152,  155 
Tendon,  contraction,  118 

whitlow,  218 

sheath,  fibroma  of,  96,  116,  118 
Tendovaginitis,  tuberculous,  342 
Teno-svnovitis,  81 
Teratology,  381 
Teratoma,  44,  381,  401 


418 


Testicle,  tuberculosis,  317,  341 
Tetania,  strum ipriva,  88 
Thiersch's  grafts,  108 
Thrombo-phlebitis,  186 
Toe-nails,  ingrowing.  230 
Tonsillar  hypertrophy,  44 
Tongue,  abscess  of,  12 

actinomycosis  of,  293 

bifid,  312 

carcinoma  of.  6,  13 

chancre  of,  299 

geographical.  298 

gumma  of.  299 

sj-philis,  311 
Tophi,  378 
ToxiuEemia,  263 
Triad  of  Hutchinson,  306 
Tuberculin,  322 
Tuberculosis,  317 

of  bladder,  333,  341 

of  bones,  325,  335 

of  glands.  324 

of  hand,  317,  342 

of  joints,  328 

of  neck,  317 

of  prostate,  341 

mUliary,  333 

of  skin,  322 

surgical,  320 

of  testicle,  317,  341 
Tumor  albus,  329,  339 

mixed,  77 

retromaxillary,  42 
Typhoid,  270 

Ulcer,  decubital,  350 

gangrenous,  350 

gimamatous,  299,  316 

moUe,  299 

phagedenic,  28 

rodent,  1 

varicose,  145 
lUcus  rodens,  1 
UmbUical  hernia.  381 
Unguis  incarnatus,  230 
Unna's  zinc  gelatin,  145 
Urachal  fistula,  382 
Urinary  phlegmon,  277 

Vaccination  keloids,  113 
Vagina,  fibroma  of.  96 
Valgus,  pes,  174,  177 
Varicocele,  174 
Varicose  ulcer  of  leg,  145 
Varix,  174 

aneurismal,  170 

cirsoid,  174 

submucous,  174 
Vascular  n£e\'us,  155 
Villous  cancer,  90 

polj-pus,  90 
Von  Recklinghausen's  disease,  389 
V-phlegmon,  215 

Wart,  30 

White  leg,  187 

White  swelling,  329,  339 


Whitlow,  213  AVhitlow,  tendinous,  226 

articular,  224  Wooden  phlegmon,  238 

chronic,  229  Wound  diphtheria,  234 

mterdigital,  227  Wounds,  treatment  of,  235 

osteal,  224  Wrist,  ganglion  of,  80 
perioste;U,  224 

peri-ungual,  228  Xeroderma  pigmentosum,  1,  33 

subcutaneous,  223  X-ray  burns,  365 
subepidermal,  222 

sub-ungual,  228  Yaws,  46 


419 


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